Provider Demographics
NPI:1376853036
Name:DAWSON, MICHEAL SHAWN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHEAL
Middle Name:SHAWN
Last Name:DAWSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:5640 S 3500 W
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-9158
Practice Address - Country:US
Practice Address - Phone:801-773-2838
Practice Address - Fax:801-773-3025
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2015-11-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT352301-1206363A00000X
CO0003660363A00000X
KS15-01671363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000076605 (IHC)Medicare PIN