Provider Demographics
NPI:1821627746
Name:HASKELL, BROCK
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:HASKELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11620 S STATE ST STE 1403
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7124
Mailing Address - Country:US
Mailing Address - Phone:385-302-7369
Mailing Address - Fax:385-247-8023
Practice Address - Street 1:11620 S STATE ST STE 1403
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7124
Practice Address - Country:US
Practice Address - Phone:385-302-7369
Practice Address - Fax:385-247-8023
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-02
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57989363A00000X
UT11856179-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant