Provider Demographics
NPI:1538711882
Name:GWILLIAM, VANINA JUDITH
Entity type:Individual
Prefix:
First Name:VANINA
Middle Name:JUDITH
Last Name:GWILLIAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N MARIO CAPECCHI DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1103
Mailing Address - Country:US
Mailing Address - Phone:801-662-4700
Mailing Address - Fax:801-662-4833
Practice Address - Street 1:100 N MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-662-4700
Practice Address - Fax:801-662-4833
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2024-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7391533-1206363A00000X
WAPA61146067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant