Provider Demographics
NPI:1972597946
Name:POWELL, JOHN JACOB (PA C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JACOB
Last Name:POWELL
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 1:292 SOUTH 1470 EAST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7000
Mailing Address - Country:US
Mailing Address - Phone:435-628-9200
Mailing Address - Fax:435-674-5763
Practice Address - Street 1:292 SOUTH 1470 EAST
Practice Address - Street 2:SUITE100
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7000
Practice Address - Country:US
Practice Address - Phone:435-628-9200
Practice Address - Fax:435-674-5763
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT47473981206207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P58743Medicare UPIN
005597202Medicare ID - Type Unspecified