Healthcare Provider Details

I. General information

NPI: 1912755323
Provider Name (Legal Business Name): LIESL HADLEY PA-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3556 W 9800 S STE 101
SOUTH JORDAN UT
84095-3221
US

IV. Provider business mailing address

PO BOX 100253
ATLANTA GA
30384-0253
US

V. Phone/Fax

Practice location:
  • Phone: 801-567-9780
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14245330-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number14245330-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: