Healthcare Provider Details

I. General information

NPI: 1689906976
Provider Name (Legal Business Name): PREMIER PLASTIC SURGERY GROUP OF UTAH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2010
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11762 S STATE ST STE 220
DRAPER UT
84020-7156
US

IV. Provider business mailing address

11762 S STATE ST STE 220
DRAPER UT
84020-7156
US

V. Phone/Fax

Practice location:
  • Phone: 801-571-2020
  • Fax: 801-571-6899
Mailing address:
  • Phone: 801-571-2020
  • Fax: 801-571-6899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE WHITE
Title or Position: SECRETARY
Credential:
Phone: 801-571-2020