Basic Information
| Provider Information | |||||||||
| NPI: | 1710388160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAYMOND | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | SMITH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 W 7200 S | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MIDVALE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840471043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8018583461 | ||||||||
| FaxNumber: | 8019552389 | ||||||||
| Practice Location | |||||||||
| Address1: | 4745 S 3200 W | ||||||||
| Address2: | |||||||||
| City: | TAYLORSVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841292822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019646214 | ||||||||
| FaxNumber: | 8774974661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2014 | ||||||||
| LastUpdateDate: | 11/09/2016 | ||||||||
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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 | 363A00000X | 9133379-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.