Provider Demographics
NPI:1417017740
Name:WILCOX, JUSTIN CARL (PA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:CARL
Last Name:WILCOX
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10011 CENTENNIAL PKWY
Mailing Address - Street 2:STE. 150
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-4156
Mailing Address - Country:US
Mailing Address - Phone:801-545-8480
Mailing Address - Fax:801-545-8495
Practice Address - Street 1:10011 CENTENNIAL PKWY
Practice Address - Street 2:STE. 150
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-4156
Practice Address - Country:US
Practice Address - Phone:801-545-8480
Practice Address - Fax:801-545-8495
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTMW 1480603363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant