Provider Demographics
NPI:1295003234
Name:SIEBENHAAR, ABBIE LYN (PAC)
Entity Type:Individual
Prefix:
First Name:ABBIE
Middle Name:LYN
Last Name:SIEBENHAAR
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6360 S 3000 E
Mailing Address - Street 2:STE 220
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6923
Mailing Address - Country:US
Mailing Address - Phone:801-944-3199
Mailing Address - Fax:801-944-3180
Practice Address - Street 1:6360 S 3000 E
Practice Address - Street 2:STE 310
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-6923
Practice Address - Country:US
Practice Address - Phone:801-944-3199
Practice Address - Fax:801-944-3180
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9505091-1206363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5059OtherAZ LIC
UT9505091-1206OtherUT LICENSE