Provider Demographics
NPI:1316670284
Name:MOCK, KATELYN (PA-S)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:MOCK
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7085 N 2200 W APT 1F
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-8234
Mailing Address - Country:US
Mailing Address - Phone:540-455-0854
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR CLINIC #4
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0002
Practice Address - Country:US
Practice Address - Phone:801-581-2719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13565320-1206207N00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology