Provider Demographics
NPI:1194701920
Name:ENGELBERT-FENTON, MICHAEL DAVID (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:ENGELBERT-FENTON
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 1:6275 SNOWVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-6118
Mailing Address - Country:US
Mailing Address - Phone:435-645-7852
Mailing Address - Fax:
Practice Address - Street 1:150 S 1000 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1443
Practice Address - Country:US
Practice Address - Phone:801-363-4071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT102950-1206207Q00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine