Healthcare Provider Details

I. General information

NPI: 1003469867
Provider Name (Legal Business Name): KYLE ALLAN VANCE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10433 S REDWOOD RD STE B
SOUTH JORDAN UT
84095-8502
US

IV. Provider business mailing address

PO BOX 95590
SOUTH JORDAN UT
84095-0590
US

V. Phone/Fax

Practice location:
  • Phone: 801-260-1919
  • Fax:
Mailing address:
  • Phone: 801-352-9500
  • Fax: 801-352-7976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11353630-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: