1336610450 NPI number — CORY MICHAEL RICE PA-C

Table of content: CORY MICHAEL RICE PA-C (NPI 1336610450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336610450 NPI number — CORY MICHAEL RICE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RICE
Provider First Name:
CORY
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336610450
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1247 S 860 W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84601-6516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-369-1085
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12176 S 1000 E STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DRAPER
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84020-3221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-572-3750
Provider Business Practice Location Address Fax Number:
801-572-1097
Provider Enumeration Date:
12/16/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  11046461-1206 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 07231979 . This is a "DOB" identifier . This identifiers is of the category "OTHER".




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