Provider Demographics
NPI:1932749538
Name:MCOMIE, STAYLER
Entity Type:Individual
Prefix:
First Name:STAYLER
Middle Name:
Last Name:MCOMIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 435
Mailing Address - Street 2:
Mailing Address - City:FERRON
Mailing Address - State:UT
Mailing Address - Zip Code:84523-0435
Mailing Address - Country:US
Mailing Address - Phone:801-214-4665
Mailing Address - Fax:
Practice Address - Street 1:520 SUPERIOR AVE STE 255
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3668
Practice Address - Country:US
Practice Address - Phone:951-756-2152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6111559-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily