MEDICARE: DEIDRE CONOVER 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	PA9103681	FL
2	363A00000X	Physician Assistant	201550-1206	UT

General Provider Information

NPI Number	:	1982741492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEIDRE CONOVER PA-C

Provider Business Mailing Address
First Line	:	4950 S LINCOLN ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-5005
Country	:	US
Telephone Number	:	386-789-2935
Fax Number	:

Provider Business Practice Location Address
First Line	:	10433 S REDWOOD RD
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84095-8502
Country	:	US
Telephone Number	:	801-260-1919
Fax Number	:

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

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	01/08/2017

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Directions to “ DEIDRE CONOVER PA-C” Practice Location

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