Provider Demographics
NPI:1053327312
Name:CLINE, JANIS K (PAC)
Entity Type:Individual
Prefix:
First Name:JANIS
Middle Name:K
Last Name:CLINE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3584 W. 9000 S.
Mailing Address - Street 2:SUITE 311
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-4775
Mailing Address - Country:US
Mailing Address - Phone:801-566-8304
Mailing Address - Fax:801-566-8330
Practice Address - Street 1:3584 W. 9000 S.
Practice Address - Street 2:SUITE 311
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-4775
Practice Address - Country:US
Practice Address - Phone:801-566-8304
Practice Address - Fax:801-566-8330
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT105404-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT470897660008Medicaid
S94612Medicare UPIN
005713103Medicare ID - Type Unspecified