Basic Information
| Provider Information | |||||||||
| NPI: | 1912598178 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAWCETT | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 533 W STATE RD SUITE 103 | ||||||||
| Address2: | |||||||||
| City: | PLEASANT GROVE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84062 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 533 W STATE RD SUITE 103 | ||||||||
| Address2: | |||||||||
| City: | PLEASANT GROVE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015066695 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2021 | ||||||||
| LastUpdateDate: | 01/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | N | Other Service Providers | Community Health Worker | 106S00000X | Y |
No ID Information.