Provider Demographics
NPI:1760673115
Name:HARLAN, MICHAEL SEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SEAN
Last Name:HARLAN
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 1:4932 S 3425 W
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-8656
Mailing Address - Country:US
Mailing Address - Phone:801-309-6174
Mailing Address - Fax:
Practice Address - Street 1:4932 S 3425 W
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-8656
Practice Address - Country:US
Practice Address - Phone:801-309-6174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
UT57954461206363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005561610Medicare PIN
UTQ38135Medicare UPIN