Basic Information
| Provider Information | |||||||||
| NPI: | 1659388791 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOAM | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | DEREK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3725 W 4100 S | ||||||||
| Address2: | |||||||||
| City: | WEST VALLEY CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841205530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019653600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12391 S 4000 W | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840967012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013021700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 01/09/2017 | ||||||||
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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 | 207Q00000X | 932663531205 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.