Provider Demographics
NPI:1255597043
Name:GRACEY, NATHAN (MPAS, PA-C)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:GRACEY
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N 500 E
Mailing Address - Street 2:STE 370
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2468
Mailing Address - Country:US
Mailing Address - Phone:435-755-2100
Mailing Address - Fax:435-752-0478
Practice Address - Street 1:325 W. LOGAN HIGHWAY
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:UT
Practice Address - Zip Code:84028
Practice Address - Country:US
Practice Address - Phone:435-946-3660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7029019-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical