Healthcare Provider Details

I. General information

NPI: 1376226936
Provider Name (Legal Business Name): ALYSSA IRENE FREDBO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2023
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

2100 PARK AVE UNIT 682858
PARK CITY UT
84068-4615
US

V. Phone/Fax

Practice location:
  • Phone: 651-323-8334
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13455633-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number13455633-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: