Provider Demographics
NPI:1972780534
Name:MEMMOTT, MARTIN HOWARD (PA)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:HOWARD
Last Name:MEMMOTT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 W 800 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-3626
Mailing Address - Country:US
Mailing Address - Phone:801-226-6184
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:960 W 800 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-3626
Practice Address - Country:US
Practice Address - Phone:801-226-6184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-25
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6853842-1206363A00000X
ORPA174028363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500690161Medicaid