Healthcare Provider Details

I. General information

NPI: 1306741327
Provider Name (Legal Business Name): ADDISON FOLTA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 CIRCLE OF HOPE DR
SALT LAKE CITY UT
84112-5500
US

IV. Provider business mailing address

PO BOX 681668
FRANKLIN TN
37068-1668
US

V. Phone/Fax

Practice location:
  • Phone: 801-646-4255
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14311846-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: