Provider Demographics
NPI:1790413359
Name:BLACK, CHRISTOPHER (APRN)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1072 E 920 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-4327
Mailing Address - Country:US
Mailing Address - Phone:801-361-2255
Mailing Address - Fax:
Practice Address - Street 1:13020 S FORT ST
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9294
Practice Address - Country:US
Practice Address - Phone:801-361-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9152128-4405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health