| Doctor Name: | KELLY D MIKESELL |
| NPI Number: | 1023200888 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PA-C |
| License Number: | 5244260-1206 |
| Business Practice Address: | 3570 W 9000 S Ste 200 West Jordan, UT - 840888875 |
| Business Phone Number: | 8015669211 |
| Business Fax Number: | 8015665667 |
| Mailing Address: | 3570 W 9000 S Ste 200, WEST JORDAN |
| State: | UT |
| Postal Code: | 840888875 |
| Phone Number: | 8015669211 |
| Fax Number: | 8015665667 |
| NPI Enumeration Date: | 08/15/2007 |
| NPI Last Update Date: | 10/13/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | 5244260-1206 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | UT |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |