Provider Demographics
NPI:1467978064
Name:DAWE, IAN MATTHEW (FNP-C)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:MATTHEW
Last Name:DAWE
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 W 1100 N
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-9647
Mailing Address - Country:US
Mailing Address - Phone:801-318-8869
Mailing Address - Fax:801-224-6010
Practice Address - Street 1:1215 S 1680 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-4939
Practice Address - Country:US
Practice Address - Phone:801-342-5409
Practice Address - Fax:801-224-6010
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT177817-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID70178OtherIDAHO APRN-CNP
UT3005394Medicaid