Healthcare Provider Details

I. General information

NPI: 1114377355
Provider Name (Legal Business Name): KIEREN MARIE KAVENEY LUPO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2016
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 S AVENUE A
YUMA AZ
85364-7170
US

IV. Provider business mailing address

2400 S AVENUE A DEPARTMENT OF EMERGENCY MEDICINE
YUMA AZ
85364
US

V. Phone/Fax

Practice location:
  • Phone: 928-344-2000
  • Fax:
Mailing address:
  • Phone: 928-344-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberOT016975
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number008578
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: