Healthcare Provider Details

I. General information

NPI: 1104888718
Provider Name (Legal Business Name): DANETTE STUART PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 09/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

698 12TH ST
OGDEN UT
84404-6200
US

IV. Provider business mailing address

1055 N 500 W STE 260
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 801-354-8225
  • Fax: 801-418-0941
Mailing address:
  • Phone: 801-375-8858
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number102410-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: