Provider Demographics
NPI:1760610349
Name:MONROY, CARISSA S (MD)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:S
Last Name:MONROY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:
Other - Last Name:SORENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2240 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-1511
Mailing Address - Country:US
Mailing Address - Phone:801-393-5355
Mailing Address - Fax:801-394-4609
Practice Address - Street 1:22 S STATE ST
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84015-1043
Practice Address - Country:US
Practice Address - Phone:801-393-5355
Practice Address - Fax:801-394-4609
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT74191611205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000067759Medicare PIN