Provider Demographics
NPI:1205070091
Name:SYDDALL, TRACY R (PA-C)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:R
Last Name:SYDDALL
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 1:10479 S SAGE VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-3955
Mailing Address - Country:US
Mailing Address - Phone:801-243-6178
Mailing Address - Fax:
Practice Address - Street 1:1525 W 2100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-1401
Practice Address - Country:US
Practice Address - Phone:801-213-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-24
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7270173-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical