Provider Demographics
NPI:1073543872
Name:DUVERNAY, PATRICE ANN (MD)
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:ANN
Last Name:DUVERNAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PATRICE
Other - Middle Name:A
Other - Last Name:DUVERNAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
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:801-535-8163
Mailing Address - Fax:801-355-4011
Practice Address - Street 1:324 10TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-2869
Practice Address - Country:US
Practice Address - Phone:801-408-7540
Practice Address - Fax:801-408-2886
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT183098-12052084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005545609Medicare PIN
F56154Medicare UPIN
UT000062199Medicare PIN
UT000062227Medicare PIN
UT006901529Medicare PIN
UT006999016Medicare PIN