Provider Demographics
NPI:1114060142
Name:COLE, MICHAEL J (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:COLE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1055 N 500 W ATTN: CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1055 N 500 W
Practice Address - Street 2:STE 101
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-373-4366
Practice Address - Fax:801-429-8191
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT262229-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant