Provider Demographics
NPI:1538357488
Name:NODA, GRACE AKIKO (PA)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:AKIKO
Last Name:NODA
Suffix:
Gender:F
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 58108
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84158-0108
Mailing Address - Country:US
Mailing Address - Phone:801-581-3998
Mailing Address - Fax:
Practice Address - Street 1:590 WAKARA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1200
Practice Address - Country:US
Practice Address - Phone:801-581-3998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6615551-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant