Healthcare Provider Details

I. General information

NPI: 1366917577
Provider Name (Legal Business Name): KEVIN DALE NEWBOLD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3895 HARRISON BLVD
OGDEN UT
84403-2312
US

IV. Provider business mailing address

36 S STATE ST
SALT LAKE CITY UT
84111-1401
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-7678
  • Fax: 801-387-8538
Mailing address:
  • Phone: 801-442-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number8984745-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number8984745-4405
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8984745-4405
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number8984745-4405
License Number StateUT
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8984745-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: