Healthcare Provider Details

I. General information

NPI: 1477016574
Provider Name (Legal Business Name): ALYSSA C PUTTKAMMER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5169 S COTTONWOOD ST STE 410
MURRAY UT
84107-6769
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-1600
  • Fax:
Mailing address:
  • Phone: 18-507-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4636-23
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12830622-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: