Provider Demographics
NPI:1871013839
Name:SALAY, JOHANNA SAGE (MS, MD)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:SAGE
Last Name:SALAY
Suffix:
Gender:F
Credentials:MS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 S CHIPETA WAY STE A
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1261
Mailing Address - Country:US
Mailing Address - Phone:801-581-7914
Mailing Address - Fax:
Practice Address - Street 1:375 S CHIPETA WAY STE A
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1261
Practice Address - Country:US
Practice Address - Phone:801-581-7914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP04109207Q00000X
UT11414333-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RILP04109OtherRHODE ISLAND LICENSE