Provider Demographics
NPI:1841692894
Name:BELNAP, CORY B (PA-C)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:B
Last Name:BELNAP
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 1:5848 S FASHION BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6175
Mailing Address - Country:US
Mailing Address - Phone:801-314-4195
Mailing Address - Fax:801-314-4015
Practice Address - Street 1:5848 S FASHION BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-6175
Practice Address - Country:US
Practice Address - Phone:801-314-4195
Practice Address - Fax:801-314-4015
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-005338363A00000X
UT7413375-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400181637Medicare PIN