Provider Demographics
NPI:1790797959
Name:BANK, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BANK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4465 S 900 E
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2456
Mailing Address - Country:US
Mailing Address - Phone:801-266-2777
Mailing Address - Fax:801-266-1377
Practice Address - Street 1:4465 S 900 E
Practice Address - Street 2:SUITE 200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-2456
Practice Address - Country:US
Practice Address - Phone:801-266-2777
Practice Address - Fax:801-266-1377
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5391997-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1790797959Medicaid
UT000062393Medicare PIN
UTP00459993Medicare PIN
UT1790797959Medicaid