Provider Demographics
NPI:1306394697
Name:HUMPHREY, MICHAEL R (WHNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7321 BALMER ST
Mailing Address - Street 2:
Mailing Address - City:HILL AFB
Mailing Address - State:UT
Mailing Address - Zip Code:84056-5012
Mailing Address - Country:US
Mailing Address - Phone:801-777-7028
Mailing Address - Fax:
Practice Address - Street 1:7321 BALMER ST
Practice Address - Street 2:
Practice Address - City:HILL AFB
Practice Address - State:UT
Practice Address - Zip Code:84056-5012
Practice Address - Country:US
Practice Address - Phone:801-777-7028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP141946363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Single Specialty