Provider Demographics
NPI:1649264664
Name:SEXTON, EMMETT WAYNE
Entity type:Individual
Prefix:
First Name:EMMETT
Middle Name:WAYNE
Last Name:SEXTON
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:PO BOX 27688
Mailing Address - Street 2:SALT LAKE CITY
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0688
Mailing Address - Country:US
Mailing Address - Phone:801-534-1360
Mailing Address - Fax:801-366-9883
Practice Address - Street 1:89 E FISH HATCHERY RD
Practice Address - Street 2:
Practice Address - City:MANTUA
Practice Address - State:UT
Practice Address - Zip Code:84324-4379
Practice Address - Country:US
Practice Address - Phone:435-225-5836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT216299-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD2245Medicaid
UTD2245Medicaid
UT005582306Medicare ID - Type Unspecified