Provider Demographics
NPI:1306198924
Name:AVERETT, KELLY R (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:AVERETT
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 1:470 E 3900 S
Mailing Address - Street 2:STE 200
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-1880
Mailing Address - Country:US
Mailing Address - Phone:801-262-9782
Mailing Address - Fax:801-262-8632
Practice Address - Street 1:1050 E SOUTH TEMPLE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1507
Practice Address - Country:US
Practice Address - Phone:801-350-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-05
Last Update Date:2022-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4850503-1206363AS0400X, 363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical