Provider Demographics
NPI:1942524566
Name:BEAR, AUTUMN (LAC)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:BEAR
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5532 LILLEHAMMER LN STE 102
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-6078
Mailing Address - Country:US
Mailing Address - Phone:646-415-1406
Mailing Address - Fax:971-397-0394
Practice Address - Street 1:5532 LILLEHAMMER LN STE 102
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-6078
Practice Address - Country:US
Practice Address - Phone:435-659-7633
Practice Address - Fax:971-397-0394
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-25
Last Update Date:2025-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0042741171100000X
UT11896562-1201171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist