Provider Demographics
NPI:1932240207
Name:DOUGLAS, DAVID (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5312 W SHAGGY PEAK DR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-6418
Mailing Address - Country:US
Mailing Address - Phone:801-792-3635
Mailing Address - Fax:801-446-1305
Practice Address - Street 1:5312 W SHAGGY PEAK DR
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-6418
Practice Address - Country:US
Practice Address - Phone:801-792-3635
Practice Address - Fax:801-446-1305
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT51755361206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT51755361206OtherSTATE LICENSE
UT51755361206OtherSTATE LICENSE
UTP63785Medicare UPIN