Provider Demographics
NPI:1639794860
Name:DEGROOT, COLLEEN (PA-S)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:
Last Name:DEGROOT
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:872 W HIGHWAY 40
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2416
Mailing Address - Country:US
Mailing Address - Phone:435-789-6677
Mailing Address - Fax:435-789-6678
Practice Address - Street 1:872 W HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2416
Practice Address - Country:US
Practice Address - Phone:435-789-6677
Practice Address - Fax:435-789-6677
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT11248938-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program