MEDICARE: GRETEL K CRISON DPM

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	213E00000X	Podiatrist	295448-0501	UT

General Provider Information

NPI Number	:	1629187547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRETEL K CRISON DPM

Provider Business Mailing Address
First Line	:	8734 S PIPER LN
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84093-1426
Country	:	US
Telephone Number	:	801-839-8337
Fax Number	:	844-477-2511

Provider Business Practice Location Address
First Line	:	3024 WEST 300 NORTH, STE C
Second Line	:
City	:	WEST POINT
State	:	UT
Zip	:	84015
Country	:	US
Telephone Number	:	385-393-8224
Fax Number	:	385-393-8225

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	08/27/2018

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