MEDICARE: RILEY PYNE WARNER PHYSICIAN ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1104434893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RILEY PYNE WARNER PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	696 E 200 N
Second Line	:
City	:	OREM
State	:	UT
Zip	:	84097-4915
Country	:	US
Telephone Number	:	801-615-3807
Fax Number	:

Provider Business Practice Location Address
First Line	:	6750 S HIGHLAND DR
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-3019
Country	:	US
Telephone Number	:	801-685-7246
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2020
Last Update Date	:	12/22/2020

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