Provider Demographics
NPI:1356037998
Name:UDALL, ADDISON
Entity type:Individual
Prefix:
First Name:ADDISON
Middle Name:
Last Name:UDALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 WEDEMEYER ST UNIT 412
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94129-5279
Mailing Address - Country:US
Mailing Address - Phone:480-772-5353
Mailing Address - Fax:
Practice Address - Street 1:10894 S RIVER FRONT PKWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-5609
Practice Address - Country:US
Practice Address - Phone:801-878-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program