Provider Demographics
NPI:1164728960
Name:GRIMLEY, LEX KIYOSHI (PA-C)
Entity Type:Individual
Prefix:
First Name:LEX
Middle Name:KIYOSHI
Last Name:GRIMLEY
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 1:2097 N SWEET CORN DR
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:UT
Mailing Address - Zip Code:84045-8239
Mailing Address - Country:US
Mailing Address - Phone:801-471-4743
Mailing Address - Fax:
Practice Address - Street 1:5169 COTTONWOOD ST STE 520
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6767
Practice Address - Country:US
Practice Address - Phone:801-507-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-27
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7796272-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant