Provider Demographics
NPI:1215829775
Name:BOGGESS, COULSON DIRK
Entity type:Individual
Prefix:
First Name:COULSON
Middle Name:DIRK
Last Name:BOGGESS
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 E 960 S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:UT
Mailing Address - Zip Code:84653-4606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:449 E 960 S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:UT
Practice Address - Zip Code:84653-4606
Practice Address - Country:US
Practice Address - Phone:801-609-8641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-18
Last Update Date:2025-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant