Provider Demographics
NPI:1659852150
Name:STONE, ALBERT SIMON (PA-C)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:SIMON
Last Name:STONE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:ALBERT
Other - Middle Name:SIMON
Other - Last Name:FRESQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:210 N 300 W
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-2334
Mailing Address - Country:US
Mailing Address - Phone:435-724-2059
Mailing Address - Fax:
Practice Address - Street 1:210 W 300 N
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-2336
Practice Address - Country:US
Practice Address - Phone:435-722-4691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT9045633-1206OtherUTAH DEPARTMENT OF OCCUPATIONAL AND PROFESSIONAL LICENSING - PA STATE LICENSE
UT9045633-8906OtherUTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING - CONTROLLED SUBSTANCE