Provider Demographics
NPI:1861499568
Name:POWELL, ANDREW B (DPM)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:B
Last Name:POWELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:754 SOUTH MAIN
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-5504
Mailing Address - Country:US
Mailing Address - Phone:435-628-2671
Mailing Address - Fax:435-634-1601
Practice Address - Street 1:754 SOUTH MAIN
Practice Address - Street 2:SUITE 3
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5504
Practice Address - Country:US
Practice Address - Phone:435-628-2671
Practice Address - Fax:435-634-1601
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0010213E00000X, 213ES0103X
UT373663-0501213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002188023Medicaid
NV40076Medicare ID - Type Unspecified
NVV40076Medicare PIN
NV002188023Medicaid
UT005530703Medicare PIN
UTU84590Medicare UPIN
UT005530703Medicare ID - Type Unspecified