Provider Demographics
NPI:1073575114
Name:WEBER, QUINN
Entity Type:Individual
Prefix:
First Name:QUINN
Middle Name:
Last Name:WEBER
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 1:144 S 500 E
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3460 PIONEER PKWY
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-2049
Practice Address - Country:US
Practice Address - Phone:801-964-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5284356-1205207PE0004X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD5216Medicaid
UT005568627Medicare ID - Type Unspecified1050 E. SOUTH TEMPLE, SLC
UT005568336Medicare ID - Type Unspecified3460 PIONEER PKWY, WVC
UT005568429Medicare ID - Type Unspecified3580 W 9000 S, W JORDAN
UTH97007Medicare UPIN
UT005567121Medicare ID - Type Unspecified1600 ANTELOPE DR, LAYTON
UTD5216Medicaid
UT005567221Medicare ID - Type Unspecified5475 S 500 E, OGDEN