Provider Demographics
NPI:1689429680
Name:WOODLAND, JOSHUA
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:WOODLAND
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 1:144 E MARIE DR
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-2128
Mailing Address - Country:US
Mailing Address - Phone:208-488-0958
Mailing Address - Fax:
Practice Address - Street 1:1206 W SOUTH JORDAN PKWY STE D
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5519
Practice Address - Country:US
Practice Address - Phone:801-302-3801
Practice Address - Fax:801-302-7248
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-LIC-240395363LP0808X
ID79207363LP0808X
AZ307248363LP0808X
UT11772561-4405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health