Healthcare Provider Details

I. General information

NPI: 1205454428
Provider Name (Legal Business Name): BRENDAN LEE SHEVCHIK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 ROUND VALLEY DR STE 100
PARK CITY UT
84060-7552
US

IV. Provider business mailing address

PO BOX 909
LOUISVILLE KY
40201-0909
US

V. Phone/Fax

Practice location:
  • Phone: 435-655-6600
  • Fax: 435-655-2388
Mailing address:
  • Phone: 502-588-0328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number00001
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14276118-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: