Provider Demographics
NPI:1023620168
Name:AMADOR, ELISA
Entity type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:AMADOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12428 S MOSSBERG DR
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-7784
Mailing Address - Country:US
Mailing Address - Phone:801-493-5945
Mailing Address - Fax:
Practice Address - Street 1:12428 S MOSSBERG DR
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-7784
Practice Address - Country:US
Practice Address - Phone:801-493-5945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9806346-3102364SW0102X
UT9806346-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SW0102XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health