Healthcare Provider Details

I. General information

NPI: 1104203249
Provider Name (Legal Business Name): JEFFRY K KUPFER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 N TRIUMPH BLVD
LEHI UT
84043
US

IV. Provider business mailing address

1682 TEMPLE CT
BOUNTIFUL UT
84010-1508
US

V. Phone/Fax

Practice location:
  • Phone: 385-345-3000
  • Fax: 770-701-6676
Mailing address:
  • Phone: 435-559-1387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95000384
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95000384
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number7640423-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: