Provider Demographics
NPI:1164479457
Name:MAITRE, PATRICK (PA-C)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:MAITRE
Suffix:
Gender:M
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 1:481 S 400 E
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-2317
Mailing Address - Country:US
Mailing Address - Phone:435-657-9488
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-2292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4731144-1206173000000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTQ37547Medicare UPIN