Provider Demographics
NPI:1326017542
Name:CAMPBELL, BLAINE G (NP)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:G
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:835 E 4800 S
Mailing Address - Street 2:SUITE 230
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107
Mailing Address - Country:US
Mailing Address - Phone:801-716-7008
Mailing Address - Fax:888-990-1557
Practice Address - Street 1:835 E 4800 S
Practice Address - Street 2:SUITE 230
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-716-7008
Practice Address - Fax:888-990-1557
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT325671-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTQ55013Medicare UPIN
UT005566506Medicare ID - Type Unspecified