Healthcare Provider Details

I. General information

NPI: 1972036242
Provider Name (Legal Business Name): JACE MENG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date: 09/17/2018
Reactivation Date: 09/21/2018

III. Provider practice location address

30 N 1900 E RM 5R218
SALT LAKE CITY UT
84132-0002
US

IV. Provider business mailing address

30 N 1900 E RM 5R218
SALT LAKE CITY UT
84132-0002
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-7818
  • Fax:
Mailing address:
  • Phone: 801-581-7818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10988322-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: