Provider Demographics
NPI:1619252384
Name:PERAZA, EMILSE ANTONIO (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILSE
Middle Name:ANTONIO
Last Name:PERAZA
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 1:1045 E 3900 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1100
Mailing Address - Country:US
Mailing Address - Phone:801-261-2000
Mailing Address - Fax:801-262-5304
Practice Address - Street 1:1045 E 3900 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1100
Practice Address - Country:US
Practice Address - Phone:801-261-2000
Practice Address - Fax:801-262-5304
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03160363A00000X
NVPA1364363A00000X
UT6777964-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0010-03160OtherNC MEDICAL LICENSE
UT6777964-1206OtherUT PA LICENSE
NVPA1364OtherNV PA LICENSE