Healthcare Provider Details

I. General information

NPI: 1093479917
Provider Name (Legal Business Name): MEGAN NICOLE ROZMAJZL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 POMERELLE AVE STE H
BURLEY ID
83318-2068
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 208-677-6170
  • Fax: 208-878-4974
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-2194
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: