Basic Information
| Provider Information | |||||||||
| NPI: | 1699401943 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DISCOE | ||||||||
| FirstName: | MARA | ||||||||
| MiddleName: | RACHEL RABIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DISCOE | ||||||||
| OtherFirstName: | MARA | ||||||||
| OtherMiddleName: | RACHEL RABIN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MARA DISCOE, PA-C | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2200 PARK AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | PARK CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840607246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356158822 | ||||||||
| FaxNumber: | 4356158823 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 PARK AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | PARK CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840607246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356158822 | ||||||||
| FaxNumber: | 4356158823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2022 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 12945855-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.