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: 12/23/2025
Certification Date: 12/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 W 465 N STE 603
PROVIDENCE UT
84332-8006
US

IV. Provider business mailing address

560 W 465 N STE 603
PROVIDENCE UT
84332-8006
US

V. Phone/Fax

Practice location:
  • Phone: 435-557-4292
  • Fax: 502-490-4677
Mailing address:
  • Phone: 435-557-4292
  • Fax:

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: