Provider Demographics
NPI:1053938811
Name:LLAVINA, JOSEPH MICHAEL
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MICHAEL
Last Name:LLAVINA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 E 12200 S STE 101
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9723
Mailing Address - Country:US
Mailing Address - Phone:801-369-8989
Mailing Address - Fax:801-704-9741
Practice Address - Street 1:721 E 12200 S STE 101
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9723
Practice Address - Country:US
Practice Address - Phone:801-369-8989
Practice Address - Fax:801-704-9741
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-28
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11971082-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty