Provider Demographics
NPI:1033530043
Name:MADDOCK, RAIJA P (FNP, APRN)
Entity Type:Individual
Prefix:MS
First Name:RAIJA
Middle Name:P
Last Name:MADDOCK
Suffix:
Gender:F
Credentials:FNP, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2553 BEVERLY ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106
Mailing Address - Country:US
Mailing Address - Phone:801-485-5445
Mailing Address - Fax:
Practice Address - Street 1:415 EAST 3900 SOUTH
Practice Address - Street 2:MALIHEH FREE CLINIC
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-266-3700
Practice Address - Fax:801-266-3721
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-17
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT188101-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily