Provider Demographics
NPI:1497485049
Name:TIEV, JALEN MON (PA)
Entity Type:Individual
Prefix:
First Name:JALEN
Middle Name:MON
Last Name:TIEV
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9821
Mailing Address - Country:US
Mailing Address - Phone:435-363-6400
Mailing Address - Fax:
Practice Address - Street 1:412 MEADOW LN
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332-9821
Practice Address - Country:US
Practice Address - Phone:435-363-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant