Healthcare Provider Details

I. General information

NPI: 1568532125
Provider Name (Legal Business Name): JUSTIN L BRINKERHOFF PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 10/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

544 S 400 E
ST GEORGE UT
84770-3705
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 435-688-4343
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number286716-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number286716
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: