MEDICARE: DR. NATHAN GLEN DEGN OD

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	152W00000X	Optometrist	10419932-9934	UT

General Provider Information

NPI Number	:	1619498375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NATHAN GLEN DEGN OD

Provider Business Mailing Address
First Line	:	849 E 400 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-2928
Country	:	US
Telephone Number	:	801-328-2020
Fax Number	:	801-363-2201

Provider Business Practice Location Address
First Line	:	849 E 400 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-2928
Country	:	US
Telephone Number	:	801-328-2020
Fax Number	:	801-328-2020

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

Provider Enumeration Date	:	07/03/2017
Last Update Date	:	07/21/2017

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