Healthcare Provider Details

I. General information

NPI: 1760286991
Provider Name (Legal Business Name): LEAVITT WOODLAND PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2025
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

981 S MAIN ST STE 220
LOGAN UT
84321-6055
US

IV. Provider business mailing address

981 S MAIN ST STE 220
LOGAN UT
84321-6055
US

V. Phone/Fax

Practice location:
  • Phone: 435-535-1413
  • Fax: 435-287-3110
Mailing address:
  • Phone: 435-535-1413
  • Fax: 435-287-3110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: