Provider Demographics
NPI:1205142924
Name:HANSON, KEELY FITZGERALD (PA-C)
Entity type:Individual
Prefix:
First Name:KEELY
Middle Name:FITZGERALD
Last Name:HANSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KEELY
Other - Middle Name:MAYRE
Other - Last Name:FITZGERALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:476 WILLIAMS WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-2186
Mailing Address - Country:US
Mailing Address - Phone:435-259-7121
Mailing Address - Fax:435-259-3112
Practice Address - Street 1:476 WILLIAMS WAY
Practice Address - Street 2:SUITE A
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-2186
Practice Address - Country:US
Practice Address - Phone:435-259-7121
Practice Address - Fax:435-259-3112
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL 1548363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT8035121-1206OtherUT MEDICAL LICENSE
UT13520505OtherCAQH
UT1205142924OtherNPI
UTUT014851OtherUT MEDICAL LIABILITY
UT8035121-8906OtherUT CONTROLLED SUBSTANCE
UTU000088825OtherPTAN
UTU000088825OtherPTAN