Basic Information
| Provider Information | |||||||||
| NPI: | 1386667293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOULTON | ||||||||
| FirstName: | BYRON | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | AUDIOLOGIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30180 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841300180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577475 | ||||||||
| FaxNumber: | 8013577997 | ||||||||
| Practice Location | |||||||||
| Address1: | 1034 N 500 W | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013737850 | ||||||||
| FaxNumber: | 8013577997 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 57266144101 | UT | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 57266144101 | 01 | UT | UTAH STATE LICENSE | OTHER |