Basic Information
| Provider Information | |||||||||
| NPI: | 1104875574 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AL-SHUQAIRAT | ||||||||
| FirstName: | TALA'AT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013548225 | ||||||||
| FaxNumber: | 8014180941 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 W SR 164 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846531666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014654813 | ||||||||
| FaxNumber: | 8018125433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 60083151205 | UT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RS0012X | 60083151205 | UT | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RP1001X | 60083151205 | UT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 870281028000 | 05 | UT | MEDICAID | 000059100 | 01 | UT | MEDICARE | OTHER |