Healthcare Provider Details

I. General information

NPI: 1124352893
Provider Name (Legal Business Name): SARAH SCOVILLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1685 W 2200 S
SALT LAKE CITY UT
84119-1456
US

IV. Provider business mailing address

5432 E SOUTHERN AVE 101
MESA AZ
85206-2772
US

V. Phone/Fax

Practice location:
  • Phone: 801-972-8850
  • Fax:
Mailing address:
  • Phone: 801-391-3569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4524
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: