Provider Demographics
NPI:1114915741
Name:MCBRIDE, NATHAN C (PA C)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:C
Last Name:MCBRIDE
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 337
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-0337
Mailing Address - Country:US
Mailing Address - Phone:801-773-4840
Mailing Address - Fax:801-525-8151
Practice Address - Street 1:6028 S RIDGELINE DR
Practice Address - Street 2:STE 201
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6914
Practice Address - Country:US
Practice Address - Phone:801-475-5400
Practice Address - Fax:801-475-8614
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2854591206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT87065316400ZMedicaid
UT107004880101OtherIHC
P11124Medicare UPIN
UT87065316400ZMedicaid