Provider Demographics
NPI:1538634928
Name:UDY, KELSEY (PA)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:UDY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13348 S MARKET CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-8009
Mailing Address - Country:US
Mailing Address - Phone:801-923-6330
Mailing Address - Fax:
Practice Address - Street 1:10433 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8502
Practice Address - Country:US
Practice Address - Phone:801-664-3585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2022-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11473563-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant