Basic Information
| Provider Information | |||||||||
| NPI: | 1235658923 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIELIK | ||||||||
| FirstName: | CANDACE | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5546 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802175546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014753000 | ||||||||
| FaxNumber: | 8014753414 | ||||||||
| Practice Location | |||||||||
| Address1: | 5740 CRESTWOOD DR | ||||||||
| Address2: | |||||||||
| City: | SOUTH OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844054869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014797771 | ||||||||
| FaxNumber: | 8014797795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2017 | ||||||||
| LastUpdateDate: | 09/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 7433417-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1578550083 | 05 | UT | MEDICAID |