Provider Demographics
NPI:1699143263
Name:OMORI, DEREK (PA)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:OMORI
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 1:3723 W 12600 S STE 450
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7296
Mailing Address - Country:US
Mailing Address - Phone:801-285-4673
Mailing Address - Fax:
Practice Address - Street 1:3723 W 12600 S STE 450
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7296
Practice Address - Country:US
Practice Address - Phone:801-285-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-12
Last Update Date:2023-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant