Healthcare Provider Details

I. General information

NPI: 1831138403
Provider Name (Legal Business Name): KIRA D JOHNSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0100
US

IV. Provider business mailing address

127 S 500 E
SALT LAKE CITY UT
84102-1959
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-3229
  • Fax:
Mailing address:
  • Phone: 801-587-6336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5734210-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: