Healthcare Provider Details

I. General information

NPI: 1396741476
Provider Name (Legal Business Name): KIPP MORENO ROBINS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 11/27/2023
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 500 W BLDG A
PROVO UT
84604-3305
US

IV. Provider business mailing address

1055 N 500 W ATTN: CREDENTIALING
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 801-812-5033
  • Fax:
Mailing address:
  • Phone: 801-354-8225
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number1811001205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: