Healthcare Provider Details

I. General information

NPI: 1851144315
Provider Name (Legal Business Name): CHRISTIAN DEAN SIMMONS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2024
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2052 E GRAYSTONE CT
DRAPER UT
84020-9120
US

IV. Provider business mailing address

2052 E GRAYSTONE CT
DRAPER UT
84020-9120
US

V. Phone/Fax

Practice location:
  • Phone: 801-889-7136
  • Fax:
Mailing address:
  • Phone: 801-889-7136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14309797-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: