Provider Demographics
NPI:1124501226
Name:MACHADO, ROGER MARTINS (PA-C)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:MARTINS
Last Name:MACHADO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8808 S OAK LN
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-9239
Mailing Address - Country:US
Mailing Address - Phone:801-940-3880
Mailing Address - Fax:
Practice Address - Street 1:150 N MAIN ST STE 105
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-1670
Practice Address - Country:US
Practice Address - Phone:435-654-1377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10968715-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical