Basic Information
| Provider Information | |||||||||
| NPI: | 1942290804 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODONNELL | ||||||||
| FirstName: | COLLEEN | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4017 N WOLF CREEK DR | ||||||||
| Address2: | |||||||||
| City: | EDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843109894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016906456 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2132 N 1700 W STE 230 | ||||||||
| Address2: | |||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840417060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017733900 | ||||||||
| FaxNumber: | 8017733900 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 007859-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 6526009-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 02108996 | 05 | NY | MEDICAID |