Provider Demographics
NPI:1124503396
Name:WESLEY SHAYNE BOTT
Entity type:Organization
Organization Name:WESLEY SHAYNE BOTT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-798-7301
Mailing Address - Street 1:238 E 400 S
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:UT
Mailing Address - Zip Code:84651-5735
Mailing Address - Country:US
Mailing Address - Phone:801-658-9094
Mailing Address - Fax:801-658-9094
Practice Address - Street 1:238 E 400 S
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-5735
Practice Address - Country:US
Practice Address - Phone:801-658-9094
Practice Address - Fax:801-658-9094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-03
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty