Healthcare Provider Details

I. General information

NPI: 1861947632
Provider Name (Legal Business Name): LAURA BROOKE-ELLISON LOCKWOOD PA-C, MPAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2016
Last Update Date: 01/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

8812 S BLUE JAY LN
COTTONWOOD HEIGHTS UT
84121-6109
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-7818
  • Fax:
Mailing address:
  • Phone: 801-301-1790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10078763-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: