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NPI Code Detail

MEDICARE: KATIE ELAINE RIDGE MCKINNON

MEDICARE: KATIE ELAINE RIDGE MCKINNON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant13072448-1206UT

General Provider Information

NPI Number : 1811624513
Entity Type Code : Individual
Provider Name (Legal Business Name) : KATIE ELAINE RIDGE MCKINNON
Provider Business Mailing Address
First Line : 1281 CHERRY LN
Second Line :
City : PROVO
State : UT
Zip : 84604-3622
Country : US
Telephone Number : 909-915-4077
Fax Number :
Provider Business Practice Location Address
First Line : 1900 N STATE ST STE 105
Second Line :
City : PROVO
State : UT
Zip : 84604-1354
Country : US
Telephone Number : 801-655-5245
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/02/2022
Last Update Date : 01/08/2023

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Directions to “ KATIE ELAINE RIDGE MCKINNON ” Practice Location

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