Provider Demographics
NPI:1184293813
Name:COX, JUSTIN M (PA-C)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:COX
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 W 3460 N
Mailing Address - Street 2:
Mailing Address - City:ERDA
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9364
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2356 N 400 E STE 201
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-3409
Practice Address - Country:US
Practice Address - Phone:435-882-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12339394-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12339394-1206OtherLICENSE