Provider Demographics
NPI:1710215835
Name:ELROD, AMANDA LEIGH (PA-C, ATC/L)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEIGH
Last Name:ELROD
Suffix:
Gender:F
Credentials:PA-C, ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 S CHIPETA WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1260
Mailing Address - Country:US
Mailing Address - Phone:801-581-7766
Mailing Address - Fax:
Practice Address - Street 1:3690 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-4423
Practice Address - Country:US
Practice Address - Phone:801-587-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-01
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6312424-48102255A2300X
UT6312424-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer