Healthcare Provider Details

I. General information

NPI: 1922707264
Provider Name (Legal Business Name): SUSANNA PARKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MEDICAL DR STE A100
BOUNTIFUL UT
84010-4995
US

IV. Provider business mailing address

148 N 360 W
CENTERVILLE UT
84014-2139
US

V. Phone/Fax

Practice location:
  • Phone: 801-683-1062
  • Fax:
Mailing address:
  • Phone: 385-226-1821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14242213-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: