Healthcare Provider Details

I. General information

NPI: 1306154653
Provider Name (Legal Business Name): ALEXANDER GOUTTSOUL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2010
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N 1900 E
SALT LAKE CITY UT
84132-0002
US

IV. Provider business mailing address

30 N 1900 E
SALT LAKE CITY UT
84132-0002
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-1935
  • Fax: 801-587-5872
Mailing address:
  • Phone: 801-265-2212
  • Fax: 801-265-0103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number7776119-1206
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7776119-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: