MEDICARE: MS. LYNN MARIE MULVIHILL RD

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	8415704-1206	UT
2	363A00000X	Physician Assistant	8415704-1206	UT

General Provider Information

NPI Number	:	1619179140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LYNN MARIE MULVIHILL RD

Provider Business Mailing Address
First Line	:	2151 E MEADOW LARK WAY
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84093-2644
Country	:	US
Telephone Number	:	517-410-5719
Fax Number	:

Provider Business Practice Location Address
First Line	:	4465 S 900 E
Second Line	:	SUITE 200
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-2469
Country	:	US
Telephone Number	:	801-266-2777
Fax Number	:

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

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	10/22/2024

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