Healthcare Provider Details

I. General information

NPI: 1790034916
Provider Name (Legal Business Name): ERIN KIMBALL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2012
Last Update Date: 01/26/2022
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 STE 101
SOUTH JORDAN UT
84095-2481
US

V. Phone/Fax

Practice location:
  • Phone: 801-302-0899
  • Fax: 801-253-1602
Mailing address:
  • Phone: 801-302-0899
  • Fax: 801-302-0892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8413247-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: