Healthcare Provider Details

I. General information

NPI: 1346867561
Provider Name (Legal Business Name): JAMES FORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2020
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3556 W 9800 S STE 101
SOUTH JORDAN UT
84095-3221
US

IV. Provider business mailing address

3248 W CANYON MEADOW DR
SOUTH JORDAN UT
84095-5202
US

V. Phone/Fax

Practice location:
  • Phone: 801-567-9780
  • Fax:
Mailing address:
  • Phone: 801-425-8934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11934566-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: