Provider Demographics
NPI:1487305868
Name:HIGGS, BROCK ANTHONY (NP-C)
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:ANTHONY
Last Name:HIGGS
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 S STATE ST STE 107
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-5096
Mailing Address - Country:US
Mailing Address - Phone:801-288-2634
Mailing Address - Fax:801-288-1186
Practice Address - Street 1:2132 N 1700 W
Practice Address - Street 2:STE 110
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-7059
Practice Address - Country:US
Practice Address - Phone:801-779-3500
Practice Address - Fax:801-779-3508
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-17
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9629878-4405207Q00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1487305868Medicaid