MEDICARE: MRS. STACEY MICHELLE ROSEVEAR PHYSICIAN ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	4833428-1206	UT
2	363A00000X	Physician Assistant	4833428-8906	UT

General Provider Information

NPI Number	:	1316362353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STACEY MICHELLE ROSEVEAR PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	3116 S 2700 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-2823
Country	:	US
Telephone Number	:	801-201-2475
Fax Number	:

Provider Business Practice Location Address
First Line	:	3116 S 2700 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-2823
Country	:	US
Telephone Number	:	801-201-2475
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2014
Last Update Date	:	02/27/2014

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