Provider Demographics
NPI:1275530156
Name:PACE, BRAD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRAD
Middle Name:
Last Name:PACE
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 1:2086 N 1700 W
Mailing Address - Street 2:SUITE C
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041
Mailing Address - Country:US
Mailing Address - Phone:801-773-8644
Mailing Address - Fax:801-927-1591
Practice Address - Street 1:2084 N 1700 W
Practice Address - Street 2:SUITE A
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041
Practice Address - Country:US
Practice Address - Phone:801-773-8644
Practice Address - Fax:801-773-9828
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT294686-1206208D00000X
UT962946861206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTS23291Medicare UPIN
UT970026457Medicare PIN
UT000060944Medicare PIN