Basic Information
| Provider Information | |||||||||
| NPI: | 1114915741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCBRIDE | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 337 | ||||||||
| Address2: | |||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840410337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017734840 | ||||||||
| FaxNumber: | 8015258151 | ||||||||
| Practice Location | |||||||||
| Address1: | 6028 S RIDGELINE DR | ||||||||
| Address2: | STE 201 | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844056914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014755400 | ||||||||
| FaxNumber: | 8014758614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 08/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2854591206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 87065316400Z | 05 | UT | MEDICAID | 107004880101 | 01 | UT | IHC | OTHER |