Healthcare Provider Details

I. General information

NPI: 1861507675
Provider Name (Legal Business Name): KEVIN K ANDERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 N MAIN ST STE 1
MONROE UT
84754-3110
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 435-527-8865
  • Fax:
Mailing address:
  • Phone: 435-527-8865
  • Fax: 435-529-9217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number273906-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: