Healthcare Provider Details

I. General information

NPI: 1710875398
Provider Name (Legal Business Name): GRANT MICHAEL THOMSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2025
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5334 S WOODROW ST STE 100
MURRAY UT
84107-5838
US

IV. Provider business mailing address

59 N EAGLEWOOD DR
NORTH SALT LAKE UT
84054-3018
US

V. Phone/Fax

Practice location:
  • Phone: 801-935-0636
  • Fax: 801-713-0601
Mailing address:
  • Phone: 801-935-0636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: