=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245882596
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRAIG DEGEN PA-S
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2019
-----------------------------------------------------
Last Update Date | 11/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1490 E FOREMASTER DR STE 260
-----------------------------------------------------
City | ST GEORGE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84790-4502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-523-3375
-----------------------------------------------------
Fax | 435-523-3376
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1490 E FOREMASTER DR STE 260
-----------------------------------------------------
City | ST GEORGE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84790-4502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-523-3375
-----------------------------------------------------
Fax | 435-523-3376
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 9098985-1206
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------