NPIMap

Individual provider Active NPI

Mallory Iverson, PA-C

  • Physician Assistant
  • Murray, UT
National Provider Identifier
1174147961
Registry record updated Oct 25, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
12106313-1206 Issued in UT
Practice address
5121 S Cottonwood Dr
Building 2 Ste 320
Murray, UT 84107
Phone
(801) 507-3380
NPI assigned
Jun 8, 2020
Last updated
Oct 25, 2022By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 25, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X PA-2213 ID
Physician Assistant 363A00000X 12106313-1206 UT Primary

Addresses

Primary practice location

5121 S Cottonwood Dr
Building 2 Ste 320
Murray, UT 84107

Mailing address

5171 S Cottonwood St Ste 210
Murray, UT 84107-5718
Phone (801) 507-3380

Other practice location 1

3277 E Louise Dr Ste 100
Meridian, ID 83642-9360
Phone (208) 706-5217

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in UT, ID, NV3 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
I20210429002463 UT Practitioner - Physician Assistant 9739507062 Reassigns benefits to 1 organization
I20230320002428 ID Practitioner - Physician Assistant 9739507062 Reassigns benefits to 2 organizations
I20230331002030 NV Practitioner - Physician Assistant 9739507062 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2020
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Ihc Health Services IncGroup PAC ID 1850209420, 3,948 clinicians
St Lukes Clinic-Treasure Valley LLCGroup PAC ID 4981878402, 1,155 clinicians

Practice addresses (Care Compare)

2650 N Tenaya Way
Suite 201
Las Vegas, NV 89128-1110
Phone (702) 736-7154

2650 N Tenaya Way
Suite 360
Las Vegas, NV 89128-1102
Phone (801) 507-3380

3277 E Louise Dr
Suite 150
Meridian, ID 83642-9373
Phone (208) 706-8346

5121 S Cottonwood St
Murray, UT 84107-5701

5171 S Cottonwood St
Suite 210
Murray, UT 84107-5718
Phone (801) 507-3380

608 W Hays St
Boise, ID 83702-5511
Phone (208) 381-5970

610 W Hays St
Boise, ID 83702-5511
Phone (208) 381-5970

8 TH Ave and C St
LDS Hosp Eeg Phys GRP
Salt Lake City, UT 84143
Phone (801) 507-7000

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
4891CTMDClinical Psychologist

Practice roles

OrganizationSpecialtyStatusNew patients
Ihc Health Services, Inc. CurrentSince Feb 10, 2022 Accepting new patients
Ihc Health Services Inc CurrentSince Nov 15, 2022 Accepting new patients
St Lukes Clinic-Treasure Valley LLC CurrentSince Dec 1, 2022 Accepting new patients
Ihc Health Services Inc Transplant Surgery CurrentSince Dec 23, 2022 Accepting new patients
Ihc Health Services Inc CurrentSince Feb 10, 2022 Accepting new patients
St Lukes Regional Medical Center Past Accepting new patients

Locations

610 W Hays St
Boise, ID 83702
Phone (208) 345-3530

3277 E Louise Dr
Ste 100
Meridian, ID 83642
Phone (208) 706-5217

3277 E Louise Dr
Ste 150
Meridian, ID 83642
Phone (208) 388-7239

444 Hospital Way
Pocatello, ID 83201
Phone (208) 232-6214

2650 N Tenaya Way
Ste 201
Las Vegas, NV 89128
Phone (702) 736-7154

786 W Pioneer Blvd
Ste A
Mesquite, NV 89027
Phone (435) 251-2500

5171 S Cottonwood St
Ste 210
Salt Lake City, UT 84107

400 C St
Salt Lake Cty, UT 84143
Phone (435) 688-4080

1380 E Medical Center Dr
Ste 4500
St George, UT 84790
Phone (435) 251-2501

Organizations & group practices 9

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 6

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1591574400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1666656000000",
    "number": "1174147961",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5171 S COTTONWOOD ST STE 210",
            "city": "MURRAY",
            "state": "UT",
            "postal_code": "841075718",
            "telephone_number": "801-507-3380"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5121 S COTTONWOOD DR",
            "address_2": "BUILDING 2 STE 320",
            "city": "MURRAY",
            "state": "UT",
            "postal_code": "84107",
            "telephone_number": "801-507-3380"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "3277 E Louise Dr Ste 100",
            "address_purpose": "LOCATION",
            "city": "Meridian",
            "state": "ID",
            "postal_code": "836429360",
            "country_code": "US",
            "telephone_number": "208-706-5217",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "IVERSON",
        "first_name": "MALLORY",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2020-06-08",
        "last_updated": "2022-10-25",
        "certification_date": "2022-10-25",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "ID",
            "license": "PA-2213",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "UT",
            "license": "12106313-1206",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Murray, UT

Sources for this page

Verify at the official NPI Registry.