Provider Demographics
NPI:1063645554
Name:FUELLENBACH, YVONNE POTTER (PA-C)
Entity Type:Individual
Prefix:
First Name:YVONNE
Middle Name:POTTER
Last Name:FUELLENBACH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-314-4130
Mailing Address - Fax:801-314-4011
Practice Address - Street 1:5848 FASHION BLVD STE 110
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6121
Practice Address - Country:US
Practice Address - Phone:801-314-4130
Practice Address - Fax:801-314-4011
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTAPPLIED207XS0114X
UT264696-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery