MEDICARE: DEVAN MICHAEL THOMAS NURSE PRACTITIONER

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	363LF0000X	Family Nurse Practitioner	86565854405	UT

General Provider Information

NPI Number	:	1841713401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEVAN MICHAEL THOMAS NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	75 S 200 E
Second Line	:	STE 100
City	:	PROVO
State	:	UT
Zip	:	84606-3146
Country	:	US
Telephone Number	:	801-877-5801
Fax Number	:

Provider Business Practice Location Address
First Line	:	10011 S CENTENNIAL PKWY STE 350
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84070-4137
Country	:	US
Telephone Number	:	801-566-5350
Fax Number	:

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

Provider Enumeration Date	:	07/25/2017
Last Update Date	:	03/09/2020

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