Provider Demographics
NPI:1871976985
Name:MT. TIMPANOGAS FERTILITY & ENDOCRINOLOGY, PLLC
Entity type:Organization
Organization Name:MT. TIMPANOGAS FERTILITY & ENDOCRINOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HANSEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RAYNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-938-9627
Mailing Address - Street 1:880 E 9400 S STE 112
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-4134
Mailing Address - Country:US
Mailing Address - Phone:801-938-9627
Mailing Address - Fax:801-666-6915
Practice Address - Street 1:880 E 9400 S STE 112
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-4134
Practice Address - Country:US
Practice Address - Phone:801-938-9627
Practice Address - Fax:801-666-6915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-07
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207VG0400X
UT6814504-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1356319842OtherINDIVIDUAL NPI #
UT1356319842Medicaid
UT1356319842Medicaid