Provider Demographics
NPI:1023200888
Name:MIKESELL, KELLY D (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:D
Last Name:MIKESELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:3570 W 9000 S STE 200
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-8875
Practice Address - Country:US
Practice Address - Phone:801-566-9211
Practice Address - Fax:801-566-5667
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT5244260-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical