Provider Demographics
NPI:1104844224
Name:DEATON, DAVID LAWRENCE (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LAWRENCE
Last Name:DEATON
Suffix:
Gender:M
Credentials:PA
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 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:435-462-3471
Mailing Address - Fax:
Practice Address - Street 1:1100 S MEDICAL DR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:UT
Practice Address - Zip Code:84647-2222
Practice Address - Country:US
Practice Address - Phone:435-462-3471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA654363AM0700X
UT8469216-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHV38750Medicare ID - Type UnspecifiedMEDICARE
NVP14368Medicare UPIN