Provider Demographics
NPI:1174127773
Name:HARTVIGSEN, SHALIA (PA-C)
Entity type:Individual
Prefix:
First Name:SHALIA
Middle Name:
Last Name:HARTVIGSEN
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 1:1210 N 100 E
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-2425
Mailing Address - Country:US
Mailing Address - Phone:520-609-5808
Mailing Address - Fax:
Practice Address - Street 1:1210 N 100 E
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-2425
Practice Address - Country:US
Practice Address - Phone:520-609-5808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12029227-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant