Basic Information
| Provider Information | |||||||||
| NPI: | 1063645554 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUELLENBACH | ||||||||
| FirstName: | YVONNE | ||||||||
| MiddleName: | POTTER | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27128 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013144130 | ||||||||
| FaxNumber: | 8013144011 | ||||||||
| Practice Location | |||||||||
| Address1: | 5848 FASHION BLVD STE 110 | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841076121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013144130 | ||||||||
| FaxNumber: | 8013144011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2009 | ||||||||
| LastUpdateDate: | 04/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0114X | APPLIED | UT | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 363A00000X | 264696-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.