Basic Information
| Provider Information | |||||||||
| NPI: | 1730318445 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRUZE | ||||||||
| FirstName: | STEPHEN | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014298000 | ||||||||
| FaxNumber: | 8014298150 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | SUITE 121 | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013737350 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2009 | ||||||||
| LastUpdateDate: | 07/02/2009 | ||||||||
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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 | 363AS0400X | 7398126-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 7398126-1206 | 01 | UT | STATE LICENSE | OTHER |