Provider Demographics
NPI:1003095373
Name:MCMASTER, ADRIENNE (PA-C)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:
Last Name:MCMASTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ADRIENNE
Other - Middle Name:
Other - Last Name:PACKHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:274 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-3915
Mailing Address - Country:US
Mailing Address - Phone:435-753-1600
Mailing Address - Fax:435-753-9521
Practice Address - Street 1:2380 N 400 E STE B
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1756
Practice Address - Country:US
Practice Address - Phone:435-752-5741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-02
Last Update Date:2021-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4985108-1206363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical