Provider Demographics
NPI:1164715124
Name:DANTIS-TAN, MINERVA ABELEDA (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:MINERVA
Middle Name:ABELEDA
Last Name:DANTIS-TAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 E 4500 S
Mailing Address - Street 2:STE 210
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4520
Mailing Address - Country:US
Mailing Address - Phone:801-288-2634
Mailing Address - Fax:801-288-1186
Practice Address - Street 1:650 E 4500 S
Practice Address - Street 2:STE 210
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-4520
Practice Address - Country:US
Practice Address - Phone:801-288-2634
Practice Address - Fax:801-288-1186
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5291704-4405363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1164715124Medicaid