Provider Demographics
NPI:1477228427
Name:RIEBER, TOM
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:RIEBER
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 1:2841 E 2100 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-1446
Mailing Address - Country:US
Mailing Address - Phone:310-403-9493
Mailing Address - Fax:
Practice Address - Street 1:1200 E 3900 S
Practice Address - Street 2:
Practice Address - City:MILLCREEK
Practice Address - State:UT
Practice Address - Zip Code:84124-1300
Practice Address - Country:US
Practice Address - Phone:801-268-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9754454-8900363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner