Provider Demographics
NPI:1487207478
Name:TERRAZAS, MOISES
Entity type:Individual
Prefix:
First Name:MOISES
Middle Name:
Last Name:TERRAZAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 S 3270 W
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-1119
Mailing Address - Country:US
Mailing Address - Phone:385-261-2737
Mailing Address - Fax:801-746-0420
Practice Address - Street 1:220 W 7200 S STE A
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1043
Practice Address - Country:US
Practice Address - Phone:801-566-5494
Practice Address - Fax:801-746-0420
Is Sole Proprietor?:No
Enumeration Date:2019-07-19
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program