Healthcare Provider Details

I. General information

NPI: 1821243684
Provider Name (Legal Business Name): SHANNON TAYLOR THURSTON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2008
Last Update Date: 02/05/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 WEST MAIN STREET
GREEN RIVER UT
84525
US

IV. Provider business mailing address

6405 S 3000 E STE 300
SALT LAKE CITY UT
84121-6977
US

V. Phone/Fax

Practice location:
  • Phone: 435-564-3434
  • Fax: 435-564-3214
Mailing address:
  • Phone: 801-266-3113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number7154120-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: