Healthcare Provider Details

I. General information

NPI: 1033435094
Provider Name (Legal Business Name): KAJSA ELIZABETH AFFOLTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2010
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF UTAH HOSPITAL 50 NORTH MEDICAL DRIVE
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

PO BOX 413033
SALT LAKE CITY UT
84141-3033
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2507
  • Fax:
Mailing address:
  • Phone: 801-213-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number39
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number8134258-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number8134258-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: