Provider Demographics
NPI:1336227206
Name:FONUA, JACKIE ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:ANNE
Last Name:FONUA
Suffix:
Gender:F
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 1:3354 W 7800 S
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-4506
Mailing Address - Country:US
Mailing Address - Phone:801-282-2677
Mailing Address - Fax:801-282-2050
Practice Address - Street 1:3354 W 7800 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-4506
Practice Address - Country:US
Practice Address - Phone:801-282-2677
Practice Address - Fax:801-282-2050
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT175335-1206207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP29300Medicare UPIN
UT000012428Medicare ID - Type Unspecified