Individual
SOUTSADA NIKKI KONESAVANH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
100 MARIO CAPECCHI DR, SALT LAKE CITY, UT 84112-8924
(801) 585-2341
Mailing address
100 MARIO CAPECCHI DR, SALT LAKE CITY, UT 84112-8924
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
7138480-1206
UT
363AM0700X
Medical Physician Assistant
Primary
7138480-1206
UT
Other
Enumeration date
10/06/2008
Last updated
11/17/2021
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