Healthcare Provider Details

I. General information

NPI: 1336481274
Provider Name (Legal Business Name): TIINA M THORLEY MPA, PA-C, RRT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2013
Last Update Date: 03/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5169 S COTTONWOOD ST BUILDING 2, SUITE 510
MURRAY UT
84107-6767
US

IV. Provider business mailing address

5169 S COTTONWOOD ST BUILDING 2, SUITE 510
MURRAY UT
84107-6767
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-3513
  • Fax:
Mailing address:
  • Phone: 801-507-3513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6358658-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA22848
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: