Provider Demographics
NPI:1104224815
Name:EVERETT, SAMUEL R (PA-C)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:R
Last Name:EVERETT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:DANIELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:154 E MYRTLE AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4850
Mailing Address - Country:US
Mailing Address - Phone:801-369-8989
Mailing Address - Fax:801-704-9741
Practice Address - Street 1:154 E MYRTLE AVE STE 204
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-4850
Practice Address - Country:US
Practice Address - Phone:801-369-8989
Practice Address - Fax:801-704-9741
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9492493-1206364SP0808X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN264430275Medicare PIN