=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124309711
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIN BAGLEY OBERG PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2011
-----------------------------------------------------
Last Update Date | 04/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | ROCKY MOUNTAIN DERMATOLOGY 1760 N 200 E #101
-----------------------------------------------------
City | NORTH LOGAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-787-0560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1760 N 200 E #101
-----------------------------------------------------
City | NORTH LOGAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84341
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-787-0560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA1529
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------