Healthcare Provider Details

I. General information

NPI: 1245609866
Provider Name (Legal Business Name): JOSHUA PEAY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

5444 S GREEN ST
MURRAY UT
84123-5632
US

IV. Provider business mailing address

5444 S GREEN ST
MURRAY UT
84123-5632
US

V. Phone/Fax

Practice location:
  • Phone: 801-284-1702
  • Fax:
Mailing address:
  • Phone: 801-284-1702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7612058-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: