Healthcare Provider Details

I. General information

NPI: 1609325422
Provider Name (Legal Business Name): CATHERINE VAN TASSELL P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 06/06/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 E BROWNING AVE
SALT LAKE CITY UT
84105-2114
US

IV. Provider business mailing address

631 E BROWNING AVE
SALT LAKE CITY UT
84105-2114
US

V. Phone/Fax

Practice location:
  • Phone: 801-577-5623
  • Fax:
Mailing address:
  • Phone: 801-577-5623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5331966-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: