Provider Demographics
NPI:1568763159
Name:VIS, CHRISTOPHER ANTHONY (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:ANTHONY
Last Name:VIS
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 1:238 GOLDEN WILLOW CIR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-4217
Mailing Address - Country:US
Mailing Address - Phone:801-953-4670
Mailing Address - Fax:
Practice Address - Street 1:17800 SOUTH CAMP WILLIAMS ROAD
Practice Address - Street 2:1ST BATTALION 19TH SPECIAL FORCES GROUP (AIRBORNE)
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065
Practice Address - Country:US
Practice Address - Phone:801-878-5640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-12
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7775959-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant