Healthcare Provider Details

I. General information

NPI: 1790061919
Provider Name (Legal Business Name): JEFFREY LYNN DAVIS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 01/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

389 S 900 E
SALT LAKE CITY UT
84102-2310
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 385-282-2850
  • Fax:
Mailing address:
  • Phone: 385-282-2850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8233732-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5063
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2012-0043
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: