Healthcare Provider Details

I. General information

NPI: 1093391450
Provider Name (Legal Business Name): LUKE ALLAN COUNTERMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 WILLIAMS WAY
MOAB UT
84532-2185
US

IV. Provider business mailing address

27 BEHIND THE ROCKS DR
MOAB UT
84532-3917
US

V. Phone/Fax

Practice location:
  • Phone: 435-719-3500
  • Fax:
Mailing address:
  • Phone: 616-265-2965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12492705-8906
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA59778
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12492705-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: