Basic Information
| Provider Information | |||||||||
| NPI: | 1619244977 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALLAN | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 413035 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841413035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012133900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 50 N MEDICAL DR | ||||||||
| Address2: | SOM 3C-127 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015815311 | ||||||||
| FaxNumber: | 8015853936 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2011 | ||||||||
| LastUpdateDate: | 11/25/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 4818116-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.