Healthcare Provider Details

I. General information

NPI: 1548960958
Provider Name (Legal Business Name): TINA XU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 S CHIPETA WAY
SALT LAKE CITY UT
84108-1260
US

IV. Provider business mailing address

375 S CHIPETA WAY
SALT LAKE CITY UT
84108-1260
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-7766
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14248057-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: