Healthcare Provider Details

I. General information

NPI: 1831441237
Provider Name (Legal Business Name): IAN DANIEL PRIMAVERA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2012
Last Update Date: 07/25/2022
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 N 2260 W
HURRICANE UT
84737-2034
US

IV. Provider business mailing address

75 N 2260 W
HURRICANE UT
84737-2034
US

V. Phone/Fax

Practice location:
  • Phone: 760-757-0224
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number12870631-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA22615
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: