Provider Demographics
NPI:1942290804
Name:ODONNELL, COLLEEN (PA)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:ODONNELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4017 N WOLF CREEK DR
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84310-9894
Mailing Address - Country:US
Mailing Address - Phone:801-690-6456
Mailing Address - Fax:
Practice Address - Street 1:2132 N 1700 W STE 230
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-7060
Practice Address - Country:US
Practice Address - Phone:801-773-3900
Practice Address - Fax:801-773-3900
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007859-1363A00000X
UT6526009-1206363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02108996Medicaid
NY02108996Medicaid
NYCC3930Medicare ID - Type UnspecifiedMEDICARE PROVIDER #