Provider Demographics
NPI:1245967199
Name:KEOGH, TRESS SOPHIA
Entity type:Individual
Prefix:
First Name:TRESS
Middle Name:SOPHIA
Last Name:KEOGH
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 1:3723 S 645 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1147
Mailing Address - Country:US
Mailing Address - Phone:704-999-8743
Mailing Address - Fax:
Practice Address - Street 1:3723 S 645 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-1147
Practice Address - Country:US
Practice Address - Phone:704-999-8743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13030982-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherSTUDENT