Basic Information
| Provider Information | |||||||||
| NPI: | 1487747515 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEPHANY | ||||||||
| FirstName: | GREGG | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5848 S FASHION BLVD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841076175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013144188 | ||||||||
| FaxNumber: | 8013144015 | ||||||||
| Practice Location | |||||||||
| Address1: | 5848 S 300 E | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841076121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013144900 | ||||||||
| FaxNumber: | 8013144919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 03/30/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1003 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 6717503-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 07010036 | 05 | CO | MEDICAID |