Provider Demographics
NPI:1679774970
Name:COLASURDO, PETER ANTHONY (PA-C)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:ANTHONY
Last Name:COLASURDO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8TH AVENUE AND C ST
Mailing Address - Street 2:LDS HOSPITAL, EAST 8
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84143-0001
Mailing Address - Country:US
Mailing Address - Phone:801-408-3729
Mailing Address - Fax:801-408-8453
Practice Address - Street 1:8TH AVENUE AND C ST
Practice Address - Street 2:LDS HOSPITAL, EAST 8
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84143-0001
Practice Address - Country:US
Practice Address - Phone:801-408-3729
Practice Address - Fax:801-408-8453
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6344772-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MC1524328OtherDEA LICENSE