Provider Demographics
NPI:1487071973
Name:NUTAKOR, RAPHAEL
Entity type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:
Last Name:NUTAKOR
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 1:48 W INGLENOOK DRIVE #720
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047
Mailing Address - Country:US
Mailing Address - Phone:775-287-5508
Mailing Address - Fax:
Practice Address - Street 1:1042 E FORT UNION BLVD # 123
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047
Practice Address - Country:US
Practice Address - Phone:775-287-5508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT52162171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications