Provider Demographics
NPI:1316362353
Name:ROSEVEAR, STACEY MICHELLE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:MICHELLE
Last Name:ROSEVEAR
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3116 S 2700 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-2823
Mailing Address - Country:US
Mailing Address - Phone:801-201-2475
Mailing Address - Fax:
Practice Address - Street 1:3116 S 2700 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-2823
Practice Address - Country:US
Practice Address - Phone:801-201-2475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-27
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4833428-1206363A00000X
UT4833428-8906363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant