Healthcare Provider Details

I. General information

NPI: 1285151662
Provider Name (Legal Business Name): ANGELA MARIE BANZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 02/16/2026
Certification Date: 02/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4403 HARRISON BLVD STE 4650
OGDEN UT
84403-3294
US

IV. Provider business mailing address

PO BOX 5546
DENVER CO
80217-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-3240
  • Fax:
Mailing address:
  • Phone: 801-475-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10455364-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10455364-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: