Healthcare Provider Details

I. General information

NPI: 1982741492
Provider Name (Legal Business Name): DEIDRE CONOVER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 01/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10433 S REDWOOD RD
SOUTH JORDAN UT
84095-8502
US

IV. Provider business mailing address

4950 S LINCOLN ST
SALT LAKE CITY UT
84107-5005
US

V. Phone/Fax

Practice location:
  • Phone: 801-260-1919
  • Fax:
Mailing address:
  • Phone: 386-789-2935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9103681
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number201550-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: