Healthcare Provider Details

I. General information

NPI: 1104801430
Provider Name (Legal Business Name): VANNETTE PERKINS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1912 SIDEWINDER DR # 200
PARK CITY UT
84060-7256
US

IV. Provider business mailing address

PO BOX 982012
PARK CITY UT
84098-2012
US

V. Phone/Fax

Practice location:
  • Phone: 435-602-7778
  • Fax:
Mailing address:
  • Phone: 856-296-9614
  • Fax: 856-740-0558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number13117864-1205
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number25MA05492500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: