Provider Demographics
NPI:1487720751
Name:FOOTE, NATHAN CYRUS (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:CYRUS
Last Name:FOOTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-525-2400
Mailing Address - Fax:801-525-2495
Practice Address - Street 1:745 S 2000 W
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-2303
Practice Address - Country:US
Practice Address - Phone:801-525-2400
Practice Address - Fax:801-525-2495
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7294948-8905207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000066336Medicare PIN