Provider Demographics
NPI:1881060523
Name:PECK, EMILY (PA)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:PECK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 N CHURCH ST
Mailing Address - Street 2:UNIT B301
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040-6593
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:425 MEDICAL DR
Practice Address - Street 2:SUITE 205
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4945
Practice Address - Country:US
Practice Address - Phone:801-298-3812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9500978-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical