Healthcare Provider Details

I. General information

NPI: 1588367239
Provider Name (Legal Business Name): JOSIE NICOLE WOOD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 08/23/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 N 100 W
MANILA UT
84046
US

IV. Provider business mailing address

823 N MAIN ST
FARMINGTON UT
84025-3608
US

V. Phone/Fax

Practice location:
  • Phone: 435-784-3575
  • Fax:
Mailing address:
  • Phone: 801-540-8734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: