MEDICARE: JEANETTE VERNON PHYSICIAN ASSISTANT

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	921066421206	UT

General Provider Information

NPI Number	:	1487866208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANETTE VERNON PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	999 S. W. HOYTSVILLE RD
Second Line	:
City	:	COALVILLE
State	:	UT
Zip	:	84017
Country	:	US
Telephone Number	:	435-336-2771
Fax Number	:

Provider Business Practice Location Address
First Line	:	82 NO 50 EAST
Second Line	:
City	:	COALVILLE
State	:	UT
Zip	:	84017
Country	:	US
Telephone Number	:	435-336-4403
Fax Number	:	435-336-5570

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

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	07/08/2007

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