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General NPI Number Information
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NPI Number | 1255597043
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Entity Type | Individual
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Provider Name | NATHAN GRACEY MPAS, PA-C
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Gender | Male
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Dates
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Enumeration Date | 08/01/2008
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Last Update Date | 02/24/2016
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Provider Practice Location Address
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Address Line | 325 W. LOGAN HIGHWAY
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City | GARDEN CITY
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State | UT
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Zip | 84028
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Country | US
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Telephone | 435-946-3660
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Fax |
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Provider Business Mailing Address
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Address Line | 1300 N 500 E STE 370
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City | LOGAN
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State | UT
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Zip | 84341-2468
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Country | US
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Telephone | 435-755-2100
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Fax | 435-752-0478
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 7029019-1206
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License Number State | UT
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