Healthcare Provider Details

I. General information

NPI: 1992221980
Provider Name (Legal Business Name): KIRK RONALD STEPHENS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2017
Last Update Date: 06/14/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7396 S UNION PARK AVE STE 201
MIDVALE UT
84047-6702
US

IV. Provider business mailing address

166 E 5900 S STE B111
MURRAY UT
84107-7293
US

V. Phone/Fax

Practice location:
  • Phone: 801-567-1400
  • Fax:
Mailing address:
  • Phone: 801-268-9672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10476224-1206
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number10476224-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: