Provider Demographics
NPI:1124510235
Name:MAW, KRACE CONNER
Entity type:Individual
Prefix:
First Name:KRACE
Middle Name:CONNER
Last Name:MAW
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 1:5856 HARRISON BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-2117
Mailing Address - Country:US
Mailing Address - Phone:801-475-6415
Mailing Address - Fax:
Practice Address - Street 1:5856 HARRISON BLVD STE A
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2117
Practice Address - Country:US
Practice Address - Phone:801-475-6415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-5653225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist