Provider Demographics
NPI:1508175563
Name:SESTAK, MICHELLE ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANN
Last Name:SESTAK
Suffix:
Gender:F
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 1:1756 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-4701
Mailing Address - Country:US
Mailing Address - Phone:801-254-0309
Mailing Address - Fax:801-254-1012
Practice Address - Street 1:1756 PARK AVE
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-4701
Practice Address - Country:US
Practice Address - Phone:801-254-0309
Practice Address - Fax:801-254-1012
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5707622-1206363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical