Provider Demographics
NPI:1144305699
Name:MENLOVE, MARY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:MENLOVE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:GARFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 3208
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3208
Mailing Address - Country:US
Mailing Address - Phone:801-587-6340
Mailing Address - Fax:
Practice Address - Street 1:6095 FASHION BLVD
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7397
Practice Address - Country:US
Practice Address - Phone:801-581-2955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT54164451206363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005702019Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
UTQ21968Medicare UPIN
UT008006040Medicare ID - Type UnspecifiedMEDICARE PROVIDER #