Healthcare Provider Details

I. General information

NPI: 1508306168
Provider Name (Legal Business Name): KAWIKA TUPUOLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2017
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1841 E RIVERSIDE DR STE 201
ST GEORGE UT
84790-7061
US

IV. Provider business mailing address

6013 S REDWOOD RD
TAYLORSVILLE UT
84123-5220
US

V. Phone/Fax

Practice location:
  • Phone: 435-256-8890
  • Fax: 833-907-2388
Mailing address:
  • Phone: 801-255-5131
  • Fax: 801-255-5131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: