1508347006 NPI number — SHANE RULON STRATFORD DNP, AG-ACNP

Table of content: SHANE RULON STRATFORD DNP, AG-ACNP (NPI 1508347006)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508347006 NPI number — SHANE RULON STRATFORD DNP, AG-ACNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STRATFORD
Provider First Name:
SHANE
Provider Middle Name:
RULON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DNP, AG-ACNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508347006
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 571117
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MURRAY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84157-1117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-507-9700
Provider Business Mailing Address Fax Number:
801-507-9705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4401 HARRISON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OGDEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84403-3195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-387-2800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/23/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  79812274405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com