Provider Demographics
NPI:1801802780
Name:WOOZLEY, JON BOWEN (PA-C)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:BOWEN
Last Name:WOOZLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:JON
Other - Middle Name:
Other - Last Name:WOOZLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-357-7081
Mailing Address - Fax:
Practice Address - Street 1:1134 N 500 W
Practice Address - Street 2:#100
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3383
Practice Address - Country:US
Practice Address - Phone:801-357-7081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3448341206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005707008Medicare PIN
UT000065089Medicare PIN