Provider Demographics
NPI:1073067823
Name:GIFFORD-FERGUSON, RIKI (PA-C)
Entity Type:Individual
Prefix:MS
First Name:RIKI
Middle Name:
Last Name:GIFFORD-FERGUSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 E CALBOURNE LN
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-2045
Mailing Address - Country:US
Mailing Address - Phone:717-817-1187
Mailing Address - Fax:
Practice Address - Street 1:340 E 100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1702
Practice Address - Country:US
Practice Address - Phone:801-428-3500
Practice Address - Fax:385-227-8362
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK140757363A00000X
MN13080363A00000X
NDPAC0791363A00000X
DEC5-0001079363A00000X
UT11656917-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1073067823Medicaid
MN1073067823Medicaid
ND1478061Medicaid