MEDICARE: VIET LE PAC

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	363AM0700X	Medical Physician Assistant	288757-1206	UT

General Provider Information

NPI Number	:	1669440152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIET LE PAC

Provider Business Mailing Address
First Line	:	5121 S COTTONWOOD ST BLDG 1
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-5701
Country	:	US
Telephone Number	:	801-507-4907
Fax Number	:	801-507-4792

Provider Business Practice Location Address
First Line	:	5121 S COTTONWOOD ST BLDG 1
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-5701
Country	:	US
Telephone Number	:	801-507-4907
Fax Number	:	801-507-4792

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

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	09/07/2021

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