Healthcare Provider Details

I. General information

NPI: 1295003234
Provider Name (Legal Business Name): ABBIE LYN SIEBENHAAR PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2011
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6360 S 3000 E STE 310
SALT LAKE CITY UT
84121-6923
US

IV. Provider business mailing address

6360 S 3000 E STE 220
SALT LAKE CITY UT
84121-6923
US

V. Phone/Fax

Practice location:
  • Phone: 801-944-3199
  • Fax: 801-944-3180
Mailing address:
  • Phone: 801-944-3199
  • Fax: 801-944-3180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9505091-1206
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9505091-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: