Provider Demographics
NPI:1184623829
Name:POWELL, GREG F (PA-C)
Entity type:Individual
Prefix:MR
First Name:GREG
Middle Name:F
Last Name:POWELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4052 W PIONEER PKWY STE 208
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120
Mailing Address - Country:US
Mailing Address - Phone:801-955-1232
Mailing Address - Fax:801-912-0537
Practice Address - Street 1:4052 W PIONEER PKWY
Practice Address - Street 2:STE 208
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120
Practice Address - Country:US
Practice Address - Phone:801-955-1232
Practice Address - Fax:801-912-0537
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT276639-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP92853Medicare UPIN