Provider Demographics
NPI:1518975127
Name:ORGAIN, NICOLE GRISE (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:GRISE
Last Name:ORGAIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 S 500 E STE 600
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1971
Mailing Address - Country:US
Mailing Address - Phone:801-587-6705
Mailing Address - Fax:801-715-8228
Practice Address - Street 1:2000 CIRCLE OF HOPE
Practice Address - Street 2:CLINIC 2E
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5550
Practice Address - Country:US
Practice Address - Phone:801-585-0100
Practice Address - Fax:801-585-3846
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7046321-8906363AM0700X
UT7046321-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTAP1885Medicare ID - Type Unspecified
VTP80026Medicare UPIN