Provider Demographics
NPI:1003031378
Name:LAW, EVAN R (PA-C)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:R
Last Name:LAW
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 1:444 W BOURNE CIR STE 200
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-3657
Mailing Address - Country:US
Mailing Address - Phone:801-397-3000
Mailing Address - Fax:801-397-0455
Practice Address - Street 1:444 W BOURNE CIR STE 200
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-3657
Practice Address - Country:US
Practice Address - Phone:801-776-0174
Practice Address - Fax:801-285-3904
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT361472-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1477643179OtherGROUP NPI
UT1477643179OtherGROUP NPI
UTP38879Medicare UPIN