MEDICARE: AMANDA LEIGH ELROD PA-C, ATC/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	6312424-4810	UT
2	363A00000X	Physician Assistant	6312424-1206	UT

General Provider Information

NPI Number	:	1710215835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA LEIGH ELROD PA-C, ATC/L

Provider Business Mailing Address
First Line	:	375 S CHIPETA WAY
Second Line	:	SUITE A
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1260
Country	:	US
Telephone Number	:	801-581-7766
Fax Number	:

Provider Business Practice Location Address
First Line	:	3690 S MAIN ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-4423
Country	:	US
Telephone Number	:	801-587-2525
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2009
Last Update Date	:	10/21/2021

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