Healthcare Provider Details

I. General information

NPI: 1932616695
Provider Name (Legal Business Name): KEVIN JAMES CROCKETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2018
Last Update Date: 01/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E HUNTERS HVN
SARATOGA SPRINGS UT
84045-8169
US

IV. Provider business mailing address

30 E HUNTERS HVN
SARATOGA SPRINGS UT
84045-8169
US

V. Phone/Fax

Practice location:
  • Phone: 801-400-9616
  • Fax:
Mailing address:
  • Phone: 801-400-9616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10620174-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: