Healthcare Provider Details

I. General information

NPI: 1538357488
Provider Name (Legal Business Name): GRACE AKIKO NODA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5323 S WOODROW ST STE 100
MURRAY UT
84107-5842
US

IV. Provider business mailing address

5323 S WOODROW ST STE 100
MURRAY UT
84107-5842
US

V. Phone/Fax

Practice location:
  • Phone: 801-713-0600
  • Fax: 813-713-0601
Mailing address:
  • Phone: 801-713-0600
  • Fax: 801-713-0601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6615551-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: