Provider Demographics
NPI:1104888718
Name:STUART, DANETTE (PA)
Entity type:Individual
Prefix:
First Name:DANETTE
Middle Name:
Last Name:STUART
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:STE 260
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-375-8858
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:698 12TH ST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-6200
Practice Address - Country:US
Practice Address - Phone:801-354-8225
Practice Address - Fax:801-418-0941
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT102410-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP02144Medicare UPIN
UT005568518Medicare ID - Type Unspecified630 MEDICAL DR, BOUNTIFUL
UT005568318Medicare ID - Type Unspecified3460 PIONEER PKWY, WVC