Provider Demographics
NPI:1114329810
Name:WARREN, MICHAEL NATHEN (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:NATHEN
Last Name:WARREN
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9286 S 2700 W
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-8620
Mailing Address - Country:US
Mailing Address - Phone:801-518-5116
Mailing Address - Fax:
Practice Address - Street 1:212 HIGHBRIDGE ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1981
Practice Address - Country:US
Practice Address - Phone:315-637-9116
Practice Address - Fax:315-637-0436
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8177613-48102255A2300X
363A00000X
UT8177613-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer