Provider Demographics
NPI:1720215478
Name:RAFFERTY, TRISHA (MD)
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:
Last Name:RAFFERTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRISHA
Other - Middle Name:
Other - Last Name:JORGENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-387-4500
Mailing Address - Fax:
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:STE 4875
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-4500
Practice Address - Fax:801-387-4712
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR70641208000000X
UT356022-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1720215478Medicaid
UT1720215478Medicaid