Provider Demographics
NPI: | 1922093558 |
---|---|
Name: | LOVELL, MARGARET MICHELE (PA) |
Entity Type: | Individual |
Prefix: | |
First Name: | MARGARET |
Middle Name: | MICHELE |
Last Name: | LOVELL |
Suffix: | |
Gender: | F |
Credentials: | PA |
Other - Prefix: | |
Other - First Name: | SHELLEY |
Other - Middle Name: | |
Other - Last Name: | LOVELL |
Other - Suffix: | |
Other - Last Name Type: | Other Name |
Other - Credentials: | |
Mailing Address - Street 1: | 1121 E 3900 S |
Mailing Address - Street 2: | STE C230 |
Mailing Address - City: | SALT LAKE CITY |
Mailing Address - State: | UT |
Mailing Address - Zip Code: | 84124-1297 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 801-213-4270 |
Mailing Address - Fax: | 801-585-1312 |
Practice Address - Street 1: | 1950 CIRCLE OF HOPE DR |
Practice Address - Street 2: | N1550 |
Practice Address - City: | SALT LAKE CITY |
Practice Address - State: | UT |
Practice Address - Zip Code: | 84112-5500 |
Practice Address - Country: | US |
Practice Address - Phone: | 801-213-4270 |
Practice Address - Fax: | 801-585-1312 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-09-20 |
Last Update Date: | 2018-10-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
UT | 366941-1206 | 363AM0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WA | 2006646 | Medicaid | |
OR | 500604424 | Medicaid | |
OR | 500604424 | Medicaid | |
OR | R132233 | Medicare PIN |