Healthcare Provider Details

I. General information

NPI: 1811487622
Provider Name (Legal Business Name): JACOB KEITH HOFFMANN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2018
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6322 S 3000 E STE 140
COTTONWOOD HEIGHTS UT
84121-3555
US

IV. Provider business mailing address

6322 S 3000 E STE 140
COTTONWOOD HEIGHTS UT
84121-3555
US

V. Phone/Fax

Practice location:
  • Phone: 801-733-9924
  • Fax:
Mailing address:
  • Phone: 801-733-9924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10818363-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: