Provider Demographics
NPI:1558902882
Name:MADDOX, AUSTIN SKYLOR
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:SKYLOR
Last Name:MADDOX
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 1:299 N 200 W
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7043
Mailing Address - Country:US
Mailing Address - Phone:801-815-3443
Mailing Address - Fax:801-683-8962
Practice Address - Street 1:13073 S WHEATFIELD WAY
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9253
Practice Address - Country:US
Practice Address - Phone:801-495-0946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker