Basic Information
| Provider Information | |||||||||
| NPI: | 1659454544 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETTIT | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 275 E 200 S | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841112002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003661884 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1253 NW CANAL BLVD | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977561334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415488131 | ||||||||
| FaxNumber: | 5415266608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 07/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD2006-0194 | NM | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.