Provider Demographics
NPI:1205024122
Name:BROCK, DAVID WESLEY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:WESLEY
Last Name:BROCK
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:100 N MARIO CAPECCHI DR
Mailing Address - Street 2:SUITE 250
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1103
Mailing Address - Country:US
Mailing Address - Phone:801-662-5582
Mailing Address - Fax:
Practice Address - Street 1:3550 N UNIVERSITY AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6683
Practice Address - Country:US
Practice Address - Phone:801-374-9625
Practice Address - Fax:801-374-9690
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2016-02-10
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Provider Licenses
StateLicense IDTaxonomies
UT6725565-1206363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical