Provider Demographics
NPI:1649745449
Name:BOYETTE, MARY MILNER (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MILNER
Last Name:BOYETTE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CRYSTAL
Other - Last Name:MILNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1433 N 1075 W STE 104
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-2746
Mailing Address - Country:US
Mailing Address - Phone:801-281-0869
Mailing Address - Fax:
Practice Address - Street 1:869 SAPPHIRE ST
Practice Address - Street 2:
Practice Address - City:MORGAN
Practice Address - State:UT
Practice Address - Zip Code:84050-9917
Practice Address - Country:US
Practice Address - Phone:254-228-9629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9116958-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant