Provider Demographics
NPI:1538617014
Name:DAX, MAXI EDRA (PA)
Entity type:Individual
Prefix:
First Name:MAXI
Middle Name:EDRA
Last Name:DAX
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MAXI
Other - Middle Name:EDRA
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:95 NORTH 100 EAST
Mailing Address - Street 2:P.O.BOX 738
Mailing Address - City:PANGUITCH
Mailing Address - State:UT
Mailing Address - Zip Code:84759
Mailing Address - Country:US
Mailing Address - Phone:435-690-1246
Mailing Address - Fax:
Practice Address - Street 1:200 NORTH 400 EAST
Practice Address - Street 2:
Practice Address - City:PANGUITCH
Practice Address - State:UT
Practice Address - Zip Code:84759
Practice Address - Country:US
Practice Address - Phone:435-690-1246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10079306-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical