Provider Demographics
NPI:1922534114
Name:LATHEN, DANIEL ROBERT
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ROBERT
Last Name:LATHEN
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 1:737 W 100 N
Mailing Address - Street 2:APT 8
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-2652
Mailing Address - Country:US
Mailing Address - Phone:385-250-8930
Mailing Address - Fax:
Practice Address - Street 1:344 E 100 S
Practice Address - Street 2:STE 301
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1700
Practice Address - Country:US
Practice Address - Phone:801-322-4257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-07
Last Update Date:2017-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker