Provider Demographics
NPI:1063506889
Name:DEWEESE, CHARLES KIP (APRN)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:KIP
Last Name:DEWEESE
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 S 1100 E
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1686
Mailing Address - Country:US
Mailing Address - Phone:801-350-4602
Mailing Address - Fax:
Practice Address - Street 1:82 S 1100 E
Practice Address - Street 2:SUITE 204
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1686
Practice Address - Country:US
Practice Address - Phone:801-350-4602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT206077-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT006902308Medicare PIN
UT006998002Medicare PIN