1942832159 NPI number — DRAPER DERMATOLOGY, P.C.

Table of content: (NPI 1942832159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942832159 NPI number — DRAPER DERMATOLOGY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRAPER DERMATOLOGY, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1942832159
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1325 W SOUTH JORDAN PKWY STE 103
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH JORDAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84095-9060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-232-6556
Provider Business Mailing Address Fax Number:
801-987-8467

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
196 ARROWHEAD DR STE 7
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVANSTON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82930-8752
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-232-6556
Provider Business Practice Location Address Fax Number:
801-987-8467
Provider Enumeration Date:
02/05/2020

Additional Information

Authorized Official

Authorized Official Last Name:
COOKSEY
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
801-232-6556

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 154374100 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




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