Basic Information
| Provider Information | |||||||||
| NPI: | 1831674092 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOLLENZIEN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | IVAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | ATTN. CREDENTIALING | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013548225 | ||||||||
| FaxNumber: | 8014180941 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 WEST SR 164 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014654813 | ||||||||
| FaxNumber: | 8018125433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2018 | ||||||||
| LastUpdateDate: | 04/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10990701-1206 | UT | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.