Basic Information
| Provider Information | |||||||||
| NPI: | 1700469236 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHAN | ||||||||
| FirstName: | ASHLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1530 S 700 E # A | ||||||||
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| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841052102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723333260 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11649 S 4000 W STE 200 | ||||||||
| Address2: | |||||||||
| City: | SOUTH JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840096048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012533080 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2021 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | TX | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.