Provider Demographics
NPI:1669647566
Name:PACKER, ALISSA ANN (MD)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:ANN
Last Name:PACKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9071 S 1300 W
Mailing Address - Street 2:#301
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-6672
Mailing Address - Country:US
Mailing Address - Phone:801-565-1162
Mailing Address - Fax:801-565-1168
Practice Address - Street 1:9071 S 1300 W
Practice Address - Street 2:#301
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-6672
Practice Address - Country:US
Practice Address - Phone:801-565-1162
Practice Address - Fax:801-565-1168
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6353362-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics