Healthcare Provider Details

I. General information

NPI: 1164479457
Provider Name (Legal Business Name): PATRICK MAITRE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

481 S 400 E
HEBER CITY UT
84032-2317
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2292
  • Fax:
Mailing address:
  • Phone: 435-657-9488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number4731144-1206
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4731144-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: