Provider Demographics
NPI:1972992477
Name:COTTONWOOD MEDICAL CLINIC,PLLC
Entity Type:Organization
Organization Name:COTTONWOOD MEDICAL CLINIC,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAPOLLA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:801-231-4932
Mailing Address - Street 1:8414 S KINGS COVE DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6064
Mailing Address - Country:US
Mailing Address - Phone:801-231-4932
Mailing Address - Fax:866-936-0188
Practice Address - Street 1:6671 S REDWOOD RD
Practice Address - Street 2:STE 110
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084-7488
Practice Address - Country:US
Practice Address - Phone:801-571-2452
Practice Address - Fax:866-936-0188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-21
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2121144405364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT2121144405OtherSTATE LICENSE