Healthcare Provider Details

I. General information

NPI: 1255597043
Provider Name (Legal Business Name): NATHAN GRACEY MPAS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2008
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 W. LOGAN HIGHWAY
GARDEN CITY UT
84028
US

IV. Provider business mailing address

1300 N 500 E STE 370
LOGAN UT
84341-2468
US

V. Phone/Fax

Practice location:
  • Phone: 435-946-3660
  • Fax:
Mailing address:
  • Phone: 435-755-2100
  • Fax: 435-752-0478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number7029019-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: