Healthcare Provider Details

I. General information

NPI: 1659248953
Provider Name (Legal Business Name): KYRSTANNE KAYE IDOM PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2025
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 S TAWNY DR
GRANTSVILLE UT
84029-5028
US

IV. Provider business mailing address

228 S TAWNY DR
GRANTSVILLE UT
84029-5028
US

V. Phone/Fax

Practice location:
  • Phone: 801-580-9139
  • Fax:
Mailing address:
  • Phone: 801-580-9139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: