Healthcare Provider Details

I. General information

NPI: 1871294215
Provider Name (Legal Business Name): MR. JAMISON LANE CREEKMORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 N 8000 W
SALT LAKE CITY UT
84116-3961
US

IV. Provider business mailing address

36 W PLUM ST
GRANTSVILLE UT
84029-9652
US

V. Phone/Fax

Practice location:
  • Phone: 385-215-5470
  • Fax:
Mailing address:
  • Phone: 435-494-8680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number14236708-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: