MEDICARE: LAUREN WASSEL VITALE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	14181669-1206	UT
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1447940762
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAUREN WASSEL VITALE PA-C

Provider Business Mailing Address
First Line	:	8213 S WILSON ST
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-7555
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8213 S WILSON ST
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-7555
Country	:	US
Telephone Number	:	770-540-7042
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2023
Last Update Date	:	12/08/2025

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