Provider Demographics
NPI:1205007093
Name:PULVER, MARK P (PA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:P
Last Name:PULVER
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Gender:M
Credentials:PA
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Mailing Address - Street 1:1250 E 3900 S
Mailing Address - Street 2:STE 450
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1349
Mailing Address - Country:US
Mailing Address - Phone:801-313-1010
Mailing Address - Fax:801-747-2116
Practice Address - Street 1:602 FORT UNION BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2216
Practice Address - Country:US
Practice Address - Phone:801-313-1010
Practice Address - Fax:801-747-2116
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2016-08-01
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Provider Licenses
StateLicense IDTaxonomies
UT6766665-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000062790Medicare PIN