Healthcare Provider Details

I. General information

NPI: 1245060631
Provider Name (Legal Business Name): ELIJAH NETJES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2024
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
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

2847 N AUGUSTA DR
LEHI UT
84043-5838
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-7676
  • Fax:
Mailing address:
  • Phone: 616-295-5828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number140250691206
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14025069-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: