Provider Demographics
NPI:1073284345
Name:WRIGHT, ROBERT (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WRIGHT
Suffix:
Gender:M
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 1:1055 N 500 W
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:
Practice Address - Street 1:555 W SR 164
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:UT
Practice Address - Zip Code:84653-8465
Practice Address - Country:US
Practice Address - Phone:801-465-4896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-25
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12480125-1206363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical