Provider Demographics
NPI:1760610349
Name:MONROY, CARISSA S (MD)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:S
Last Name:MONROY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:
Other - Last Name:SORENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:660 S 200 E STE 250
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-3846
Mailing Address - Country:US
Mailing Address - Phone:801-359-2256
Mailing Address - Fax:
Practice Address - Street 1:660 S 200 E STE 250
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3846
Practice Address - Country:US
Practice Address - Phone:801-359-2256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT74191611205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000067759Medicare PIN