Provider Demographics
NPI:1093479917
Name:ROZMAJZL, MEGAN NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:NICOLE
Last Name:ROZMAJZL
Suffix:
Gender:F
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:PO BOX 30180
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0180
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1408 POMERELLE AVE STE H
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2068
Practice Address - Country:US
Practice Address - Phone:208-677-6170
Practice Address - Fax:208-878-4974
Is Sole Proprietor?:No
Enumeration Date:2021-10-27
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-2194363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty