Provider Demographics
NPI:1639466352
Name:SYRACUSE FAMILY & OCCUPATIONAL MEDICINE PLLC
Entity type:Organization
Organization Name:SYRACUSE FAMILY & OCCUPATIONAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:HASTIE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP--BC
Authorized Official - Phone:801-564-7091
Mailing Address - Street 1:1842 S 2000 W #2
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-9626
Mailing Address - Country:US
Mailing Address - Phone:801-774-7450
Mailing Address - Fax:801-774-7452
Practice Address - Street 1:1842 S 2000 W # 2
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-9626
Practice Address - Country:US
Practice Address - Phone:801-774-7450
Practice Address - Fax:801-774-7452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7994885-0162261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT204722-4405OtherUT LICENSE
UT1619900339OtherAPRN NPI NUMBER
UT204722-4405OtherUT LICENSE