Provider Demographics
NPI:1144816661
Name:BLANCHARD, AUSTIN GUY
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:GUY
Last Name:BLANCHARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1548 S CARSON WAY
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:UT
Mailing Address - Zip Code:84653-5742
Mailing Address - Country:US
Mailing Address - Phone:801-380-2386
Mailing Address - Fax:
Practice Address - Street 1:1548 S CARSON WAY
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:UT
Practice Address - Zip Code:84653-5742
Practice Address - Country:US
Practice Address - Phone:801-380-2386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9801058-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty