Healthcare Provider Details

I. General information

NPI: 1174683775
Provider Name (Legal Business Name): KATHRYN RENEE MARSHALL P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 12/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10623 S REDWOOD RD SUITE 101
SOUTH JORDAN UT
84095-2481
US

IV. Provider business mailing address

10623 S REDWOOD RD SUITE 101
SOUTH JORDAN UT
84095-2481
US

V. Phone/Fax

Practice location:
  • Phone: 801-566-4242
  • Fax:
Mailing address:
  • Phone: 801-566-4242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10142002-1206
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0002238
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: