Provider Demographics
NPI:1740552843
Name:HIGUCHI, FABIO KAZUO DANTAS
Entity type:Individual
Prefix:MR
First Name:FABIO
Middle Name:KAZUO DANTAS
Last Name:HIGUCHI
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 1:13974 S 2700 W
Mailing Address - Street 2:
Mailing Address - City:BLUFFDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84065-5403
Mailing Address - Country:US
Mailing Address - Phone:801-403-7600
Mailing Address - Fax:
Practice Address - Street 1:13974 S 2700 W
Practice Address - Street 2:
Practice Address - City:BLUFFDALE
Practice Address - State:UT
Practice Address - Zip Code:84065-5403
Practice Address - Country:US
Practice Address - Phone:801-403-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001230559163W00000X
VA0024169858367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse