Healthcare Provider Details

I. General information

NPI: 1114842788
Provider Name (Legal Business Name): GARRISON DOUGLAS BEACH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 W 300 N
ROOSEVELT UT
84066-2351
US

IV. Provider business mailing address

250 W 300 N
ROOSEVELT UT
84066-2351
US

V. Phone/Fax

Practice location:
  • Phone: 435-722-4691
  • Fax:
Mailing address:
  • Phone: 435-722-4691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: