Provider Demographics
NPI:1770677478
Name:LAMBERT, JAY CANNON (PA)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:CANNON
Last Name:LAMBERT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:4095 E PONY EXPRESS PKWY
Practice Address - Street 2:STE 1
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-5529
Practice Address - Country:US
Practice Address - Phone:801-429-8037
Practice Address - Fax:801-753-7476
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT413363A00000X
UT9412400-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0071813OtherCAH MEDICARE PART B
MT4307589Medicaid
MTP00307087OtherRAILROAD MEDICARE
MT4307589Medicaid
MTG45913Medicare UPIN
MT00096663Medicare ID - Type UnspecifiedBCBS