Provider Demographics
NPI:1508665605
Name:GAUTAM, USHA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:USHA
Middle Name:
Last Name:GAUTAM
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 E HAMMERMILL LN
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-2918
Mailing Address - Country:US
Mailing Address - Phone:385-234-8696
Mailing Address - Fax:
Practice Address - Street 1:243 E HAMMERMILL LN
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2918
Practice Address - Country:US
Practice Address - Phone:385-234-8696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11176038-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner