Provider Demographics
NPI:1861490609
Name:PIERSON, JEFFERY D (PA)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:D
Last Name:PIERSON
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:PO BOX 27688
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0688
Mailing Address - Country:US
Mailing Address - Phone:801-534-1360
Mailing Address - Fax:801-366-9883
Practice Address - Street 1:3585 N UNIVERSITY AVE
Practice Address - Street 2:STE 150
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6601
Practice Address - Country:US
Practice Address - Phone:801-356-6100
Practice Address - Fax:801-356-2113
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT0285910-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP93525Medicare UPIN
UT005734303Medicare ID - Type Unspecified