Provider Demographics
NPI:1700946589
Name:JONSON, JAN CHRISTER (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JAN
Middle Name:CHRISTER
Last Name:JONSON
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 1:1055 N 500 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-812-4673
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1125 BLACKHAWK BLVD
Practice Address - Street 2:CENTRAL UTAH CLINIC FAMILY MEDICINE
Practice Address - City:MT PLEASANT
Practice Address - State:UT
Practice Address - Zip Code:84647
Practice Address - Country:US
Practice Address - Phone:435-462-2044
Practice Address - Fax:435-462-2043
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1017171206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529496984001Medicaid
UT000012637Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
UTS18946Medicare UPIN
UT000006001Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER