MEDICARE: COREY DAHL 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	363A00000X	Physician Assistant		WY
2	363A00000X	Physician Assistant	8554567-1206	UT

General Provider Information

NPI Number	:	1376891366
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COREY DAHL PA-C

Provider Business Mailing Address
First Line	:	926 SHEPARD CHURCH DR
Second Line	:
City	:	FARMINGTON
State	:	UT
Zip	:	84025-2837
Country	:	US
Telephone Number	:	801-510-8140
Fax Number	:

Provider Business Practice Location Address
First Line	:	1250 E 3900 S STE 440
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1349
Country	:	US
Telephone Number	:	801-869-4100
Fax Number	:	801-869-4119

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

Provider Enumeration Date	:	08/22/2012
Last Update Date	:	02/08/2024

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