Provider Demographics
NPI:1821752676
Name:DEIS, MARK DUWAYNE
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DUWAYNE
Last Name:DEIS
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 1:6154 S 2175 E
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5354
Mailing Address - Country:US
Mailing Address - Phone:801-726-3738
Mailing Address - Fax:
Practice Address - Street 1:6154 S 2175 E
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-5354
Practice Address - Country:US
Practice Address - Phone:801-726-3738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT56634973102163W00000X
UT5663497-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1275134132OtherCOMMERCIAL INSURANCE
UT1275134132Medicaid