Provider Demographics
NPI:1477571065
Name:LYTHGOE, TODD DALE (PA-C)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:DALE
Last Name:LYTHGOE
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:PO BOX 5546
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5546
Mailing Address - Country:US
Mailing Address - Phone:801-397-6100
Mailing Address - Fax:801-397-6101
Practice Address - Street 1:1560 RENAISSANCE TOWNE DR
Practice Address - Street 2:SUITE 210
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7680
Practice Address - Country:US
Practice Address - Phone:801-397-6100
Practice Address - Fax:801-397-6101
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8092052-1206363A00000X
CAPA21623363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S44022Medicare UPIN
UTU000094222Medicare PIN
NV37529Medicare PIN
NVP00281961OtherRAILROAD MEDICARE