Provider Demographics
NPI:1588171060
Name:PENDLETON, SHAWN M (PA-C)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:M
Last Name:PENDLETON
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 1:661 W SOUTH JORDAN PKWY
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8524
Mailing Address - Country:US
Mailing Address - Phone:801-302-2690
Mailing Address - Fax:
Practice Address - Street 1:661 W SOUTH JORDAN PKWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8524
Practice Address - Country:US
Practice Address - Phone:801-302-2690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-05
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
UT9147996-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant