Healthcare Provider Details

I. General information

NPI: 1114915741
Provider Name (Legal Business Name): NATHAN C MCBRIDE PA C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6028 S RIDGELINE DR STE 201
OGDEN UT
84405-6914
US

IV. Provider business mailing address

PO BOX 337
LAYTON UT
84041-0337
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-5400
  • Fax: 801-475-8614
Mailing address:
  • Phone: 801-773-4840
  • Fax: 801-525-8151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2854591206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: