Provider Demographics
NPI:1811947229
Name:GAFFNEY, MICHAEL RICHARD (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RICHARD
Last Name:GAFFNEY
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 1:1033 MILLSTREAM WAY
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-2119
Mailing Address - Country:US
Mailing Address - Phone:801-599-5342
Mailing Address - Fax:
Practice Address - Street 1:1033 MILLSTREAM WAY
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-2119
Practice Address - Country:US
Practice Address - Phone:801-599-5342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT262232-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT62930OtherPEHP
UT970017807Medicare ID - Type UnspecifiedRAILROAD MEDICARE
UTQMXPR0009118OtherMOLINA GROUPS
UTIDX51970OtherHEALTHY U
UTIDX51970OtherUNIVERSITY HEALTH PLANS
UT005717223Medicare PIN
UTP35368Medicare UPIN