MEDICARE: MR. DAMION D. RODEBACK PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	54658	CA
2	363A00000X	Physician Assistant	54658	CA
3	363AS0400X	Surgical Physician Assistant	PA60677483	WA
4	363A00000X	Physician Assistant	65833191206	UT

General Provider Information

NPI Number	:	1083069793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAMION D. RODEBACK PA-C

Provider Business Mailing Address
First Line	:	732 N MAIN ST
Second Line	:
City	:	SPRINGVILLE
State	:	UT
Zip	:	84663-1034
Country	:	US
Telephone Number	:	801-704-7001
Fax Number	:	801-806-0383

Provider Business Practice Location Address
First Line	:	1449 N 1400 W STE 22
Second Line	:
City	:	ST GEORGE
State	:	UT
Zip	:	84770-5237
Country	:	US
Telephone Number	:	435-703-9296
Fax Number	:	435-215-4075

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2016
Last Update Date	:	05/02/2024

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