MEDICARE: AUDREY CANNON MAT, LAT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1497535397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUDREY CANNON MAT, LAT, ATC

Provider Business Mailing Address
First Line	:	1850 E 250 S
Second Line	:	HPER WEST, ROOM 113
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84112
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1250 E 6600 S UNIT B
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84121-2451
Country	:	US
Telephone Number	:	480-297-7107
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2023
Last Update Date	:	06/02/2025

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