Healthcare Provider Details

I. General information

NPI: 1992052336
Provider Name (Legal Business Name): HEATHER RAE VAN LOON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEATHER RAE RICHARDS PA-C

II. Dates (important events)

Enumeration Date: 08/03/2012
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 CIRCLE OF HOPE HCH 4TH FLOOR
SLC UT
84112-5550
US

IV. Provider business mailing address

127 S 500 E STE 600
SLC UT
84102-1971
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-0100
  • Fax: 801-585-2935
Mailing address:
  • Phone: 801-587-6705
  • Fax: 801-715-8228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8372563-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number8372563-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: