Provider Demographics
NPI:1013555705
Name:ESTRADA, MAYRA (RN, BSN)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:ESTRADA
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 E MEDICAL TOWER DR FL 2
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4872
Mailing Address - Country:US
Mailing Address - Phone:801-314-4500
Mailing Address - Fax:801-314-2909
Practice Address - Street 1:181 E MEDICAL TOWER DR FL 2
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-4872
Practice Address - Country:US
Practice Address - Phone:801-314-4500
Practice Address - Fax:801-314-2909
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6306781-3102163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
163WD0400XOtherTAXONOMY CODE