Individual
KELLY D MIKESELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
3570 W 9000 S STE 200, WEST JORDAN, UT 84088-8875
(801) 566-9211
(801) 566-5667
Mailing address
1055 N 500 W, ATTN: CREDENTIALING, PROVO, UT 84604
(801) 354-8225
(801) 418-0941
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
5244260-1206
UT
Other
Enumeration date
08/15/2007
Last updated
02/09/2017
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