MEDICARE: JEREMY RUSSEL HARMAN 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	7095823-1206	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619967387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY RUSSEL HARMAN PA-C

Provider Business Mailing Address
First Line	:	PO BOX 27128
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84127-0128
Country	:	US
Telephone Number	:	801-408-7660
Fax Number	:

Provider Business Practice Location Address
First Line	:	324 E 10TH AVE
Second Line	:	SUITE 100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84103-2853
Country	:	US
Telephone Number	:	801-408-7660
Fax Number	:

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

Provider Enumeration Date	:	10/25/2005
Last Update Date	:	01/28/2016

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