Healthcare Provider Details

I. General information

NPI: 1922856616
Provider Name (Legal Business Name): ELISE WRIGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2024
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 NOVELL PL
PROVO UT
84606-6171
US

IV. Provider business mailing address

3556 W 9800 S STE 101
SOUTH JORDAN UT
84095-3221
US

V. Phone/Fax

Practice location:
  • Phone: 480-388-2808
  • Fax:
Mailing address:
  • Phone: 801-567-9780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14252273-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: