Healthcare Provider Details

I. General information

NPI: 1215091525
Provider Name (Legal Business Name): MATTHEW MEMMOTT NEDDO PA-C, MPAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 S LAKE PARK BLVD
WEST VALLEY CITY UT
84120-8218
US

IV. Provider business mailing address

5080 SPECTRUM DR STE 1200W
ADDISON TX
75001-4624
US

V. Phone/Fax

Practice location:
  • Phone: 801-902-4238
  • Fax: 801-266-6916
Mailing address:
  • Phone: 972-364-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number373676-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: