Healthcare Provider Details

I. General information

NPI: 1710215835
Provider Name (Legal Business Name): AMANDA LEIGH ELROD PA-C, ATC/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3690 S MAIN ST
SALT LAKE CITY UT
84115-4423
US

IV. Provider business mailing address

375 S CHIPETA WAY SUITE A
SALT LAKE CITY UT
84108-1260
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-2525
  • Fax:
Mailing address:
  • Phone: 801-581-7766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number6312424-4810
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6312424-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: