Basic Information
| Provider Information | |||||||||
| NPI: | 1144646613 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHIPPEN | ||||||||
| FirstName: | COLTON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 S 11TH AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832014880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082327962 | ||||||||
| FaxNumber: | 2082322408 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S CHIPETA WAY | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841081222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012367710 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2014 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MRO-2184 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.