Provider Demographics
NPI:1043324551
Name:FLETCHER, DIANA (PA-C)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:FLETCHER
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 1:1520 COUNTRY HILLS DR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-2512
Mailing Address - Country:US
Mailing Address - Phone:801-391-1882
Mailing Address - Fax:
Practice Address - Street 1:722 SHEPARD LN
Practice Address - Street 2:SUITE 102
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-3845
Practice Address - Country:US
Practice Address - Phone:801-447-3377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5582820-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTQ10490Medicare UPIN