Provider Demographics
NPI:1114915170
Name:GROGAN, RODNEY K (PA-C)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:K
Last Name:GROGAN
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:PO BOX 5546
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5546
Mailing Address - Country:US
Mailing Address - Phone:801-475-3900
Mailing Address - Fax:801-475-3901
Practice Address - Street 1:3485 W 5200 S
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-9438
Practice Address - Country:US
Practice Address - Phone:801-475-3900
Practice Address - Fax:801-475-3901
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1048681206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU005193005Medicare PIN
UTS18371Medicare UPIN