Healthcare Provider Details

I. General information

NPI: 1780037077
Provider Name (Legal Business Name): CRAIG PENTON APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2016
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 E MAIN ST STE 7
GRANTSVILLE UT
84029-2501
US

IV. Provider business mailing address

89 W HIDDEN ACRES LN
ERDA UT
84074-5585
US

V. Phone/Fax

Practice location:
  • Phone: 435-884-3578
  • Fax:
Mailing address:
  • Phone: 435-224-2634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number8295780-3102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8295780-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: