Healthcare Provider Details

I. General information

NPI: 1083069793
Provider Name (Legal Business Name): DAMION D. RODEBACK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2016
Last Update Date: 05/02/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1449 N 1400 W STE 22
ST GEORGE UT
84770-5237
US

IV. Provider business mailing address

732 N MAIN ST
SPRINGVILLE UT
84663-1034
US

V. Phone/Fax

Practice location:
  • Phone: 435-703-9296
  • Fax: 435-215-4075
Mailing address:
  • Phone: 801-704-7001
  • Fax: 801-806-0383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number54658
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number54658
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA60677483
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number65833191206
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: