Healthcare Provider Details

I. General information

NPI: 1528438140
Provider Name (Legal Business Name): JAMIE COY GRANGE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2015
Last Update Date: 06/24/2022
Certification Date: 06/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2245 N 400 E STE 301
LOGAN UT
84341-1892
US

IV. Provider business mailing address

2245 N 400 E STE 301
LOGAN UT
84341
US

V. Phone/Fax

Practice location:
  • Phone: 435-753-7880
  • Fax:
Mailing address:
  • Phone: 435-753-7880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number95341561206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: