MEDICARE: JEFFREY MICHAEL COURSEY PA

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	363AM0700X	Medical Physician Assistant	101498-1206	UT

General Provider Information

NPI Number	:	1477550515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY MICHAEL COURSEY PA

Provider Business Mailing Address
First Line	:	461 S 400 E
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84111-3302
Country	:	US
Telephone Number	:	801-539-8617
Fax Number	:	801-537-7238

Provider Business Practice Location Address
First Line	:	461 S 400 E
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84111-3302
Country	:	US
Telephone Number	:	801-539-8617
Fax Number	:	801-537-7238

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

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	07/08/2007

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