Provider Demographics
NPI:1366812257
Name:LAST, MEESHA (PA-C)
Entity type:Individual
Prefix:
First Name:MEESHA
Middle Name:
Last Name:LAST
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 1:295 S CHIPETA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1287
Mailing Address - Country:US
Mailing Address - Phone:801-213-3469
Mailing Address - Fax:
Practice Address - Street 1:295 S CHIPETA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1287
Practice Address - Country:US
Practice Address - Phone:801-213-3469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA079212363A00000X
UT12772097-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant