Provider Demographics
NPI:1376929299
Name:BACKMAN, SHANE ANDREW (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:ANDREW
Last Name:BACKMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N 1900 E RM 3B110
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-2101
Mailing Address - Country:US
Mailing Address - Phone:801-581-8738
Mailing Address - Fax:
Practice Address - Street 1:30 N 1900 E RM 3B110
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-2101
Practice Address - Country:US
Practice Address - Phone:801-581-8738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2021-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant