Provider Demographics
NPI:1659069318
Name:CARRANZA, WILHELM VINICIO (STUDENT)
Entity Type:Individual
Prefix:
First Name:WILHELM
Middle Name:VINICIO
Last Name:CARRANZA
Suffix:
Gender:M
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 E 3200 N
Mailing Address - Street 2:
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-1767
Mailing Address - Country:US
Mailing Address - Phone:323-637-1741
Mailing Address - Fax:
Practice Address - Street 1:990 E 3200 N
Practice Address - Street 2:
Practice Address - City:NORTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84414-1767
Practice Address - Country:US
Practice Address - Phone:323-637-1741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-28
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program