Provider Demographics
NPI:1578226288
Name:CARSON, QUINTON WAYNE
Entity Type:Individual
Prefix:
First Name:QUINTON
Middle Name:WAYNE
Last Name:CARSON
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 1:3127 E CANYON GLEN LOOP
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-9355
Mailing Address - Country:US
Mailing Address - Phone:385-254-2084
Mailing Address - Fax:
Practice Address - Street 1:3127 E CANYON GLEN LOOP
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-9355
Practice Address - Country:US
Practice Address - Phone:385-254-2084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9600073-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist