Healthcare Provider Details

I. General information

NPI: 1275812208
Provider Name (Legal Business Name): JOHN WALKER LELIS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2011
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 S COTTONWOOD ST
MURRAY UT
84107-5701
US

IV. Provider business mailing address

5121 S COTTONWOOD ST
MURRAY UT
84107-5701
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-4017
  • Fax: 801-507-4809
Mailing address:
  • Phone: 801-507-4000
  • Fax: 801-507-4809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number8516577-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: