Healthcare Provider Details

I. General information

NPI: 1285453423
Provider Name (Legal Business Name): ANDREW STOVER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2024
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-9004
US

IV. Provider business mailing address

13808 TEAL CREEK DR
BROOMFIELD CO
80023-3979
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax:
Mailing address:
  • Phone: 303-903-8205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14189932-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: