Basic Information
| Provider Information | |||||||||
| NPI: | 1649264664 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEXTON | ||||||||
| FirstName: | EMMETT | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27688 | ||||||||
| Address2: | SALT LAKE CITY | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015341360 | ||||||||
| FaxNumber: | 8013669883 | ||||||||
| Practice Location | |||||||||
| Address1: | 89 E FISH HATCHERY RD | ||||||||
| Address2: | |||||||||
| City: | MANTUA | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843244379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4352255836 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2005 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 367500000X | 216299-4406 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | D2245 | 05 | UT | MEDICAID |