Healthcare Provider Details

I. General information

NPI: 1518170042
Provider Name (Legal Business Name): JOSHUA BAILEY PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 06/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5911 FASHION BLVD
MURRAY UT
84107-7352
US

IV. Provider business mailing address

PO BOX 307
BOUNTIFUL UT
84011-0307
US

V. Phone/Fax

Practice location:
  • Phone: 801-266-6483
  • Fax: 801-266-6916
Mailing address:
  • Phone: 801-294-6907
  • Fax: 801-294-6917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5713739-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: