Provider Demographics
NPI:1205867553
Name:THACKER, PAULA G (CNM)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:G
Last Name:THACKER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3725 W 4100 SOUTH
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120
Mailing Address - Country:US
Mailing Address - Phone:801-965-3600
Mailing Address - Fax:801-965-3526
Practice Address - Street 1:3725 W 4100 SOUTH
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120
Practice Address - Country:US
Practice Address - Phone:801-965-3600
Practice Address - Fax:801-965-3526
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2132644402367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q10179Medicare UPIN