Healthcare Provider Details

I. General information

NPI: 1902967219
Provider Name (Legal Business Name): RODERICK D MAXWELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2084 N 1700 W SUITE A
LAYTON UT
84041
US

IV. Provider business mailing address

2086 N 1700 W SUITE C
LAYTON UT
84041
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-8644
  • Fax: 801-773-9828
Mailing address:
  • Phone: 801-773-8644
  • Fax: 801-927-1591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number6343294-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: