Healthcare Provider Details

I. General information

NPI: 1164164521
Provider Name (Legal Business Name): HAROON KISANA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-8525
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number74393
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number74393
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: