Provider Demographics
NPI:1275812208
Name:LELIS, JOHN WALKER (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WALKER
Last Name:LELIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5121 S COTTONWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5701
Mailing Address - Country:US
Mailing Address - Phone:801-507-4000
Mailing Address - Fax:801-507-4809
Practice Address - Street 1:5121 S COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5701
Practice Address - Country:US
Practice Address - Phone:801-507-4017
Practice Address - Fax:801-507-4809
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8516577-1206363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1275812208Medicaid