Provider Demographics
NPI:1194290767
Name:BLACK, MEGAN LOUISE (PA)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:LOUISE
Last Name:BLACK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:LOUISE
Other - Last Name:MACDONALD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:466 W 800 S
Mailing Address - Street 2:
Mailing Address - City:BLANDING
Mailing Address - State:UT
Mailing Address - Zip Code:84511-3901
Mailing Address - Country:US
Mailing Address - Phone:435-459-9682
Mailing Address - Fax:
Practice Address - Street 1:466 W 800 S
Practice Address - Street 2:
Practice Address - City:BLANDING
Practice Address - State:UT
Practice Address - Zip Code:84511-3901
Practice Address - Country:US
Practice Address - Phone:435-459-9682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11452109-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant