Provider Demographics
NPI:1104556125
Name:GROBERG, CHRISTOPHER (PA)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:GROBERG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-400-6240
Mailing Address - Fax:
Practice Address - Street 1:1300 N 500 E STE 320
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2462
Practice Address - Country:US
Practice Address - Phone:435-716-2200
Practice Address - Fax:435-716-2220
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13641879-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant