Provider Demographics
NPI:1942832159
Name:DRAPER DERMATOLOGY, P.C.
Entity Type:Organization
Organization Name:DRAPER DERMATOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COOKSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-232-6556
Mailing Address - Street 1:1325 W SOUTH JORDAN PKWY STE 103
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-9060
Mailing Address - Country:US
Mailing Address - Phone:801-232-6556
Mailing Address - Fax:801-987-8467
Practice Address - Street 1:196 ARROWHEAD DR STE 7
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-8752
Practice Address - Country:US
Practice Address - Phone:801-232-6556
Practice Address - Fax:801-987-8467
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DRAPER DERMATOLOGY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-05
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY154374100Medicaid