Provider Demographics
NPI:1104920354
Name:PACKHAM, CRAIG AARON (PA-C)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:AARON
Last Name:PACKHAM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2356 N 400 E
Mailing Address - Street 2:STE 102
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074
Mailing Address - Country:US
Mailing Address - Phone:435-833-9180
Mailing Address - Fax:435-833-9177
Practice Address - Street 1:2356 N 400 E
Practice Address - Street 2:STE 102
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074
Practice Address - Country:US
Practice Address - Phone:435-833-9180
Practice Address - Fax:435-833-9177
Is Sole Proprietor?:No
Enumeration Date:2006-09-09
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT51058218002363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD4703Medicaid
UT000065802Medicare PIN