Healthcare Provider Details

I. General information

NPI: 1689308744
Provider Name (Legal Business Name): KEVIN LYMAN PETERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2022
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3570 W 9000 S
WEST JORDAN UT
84088-8869
US

IV. Provider business mailing address

5242 S COLLEGE DR STE 200
MURRAY UT
84123-2918
US

V. Phone/Fax

Practice location:
  • Phone: 801-903-5620
  • Fax: 385-351-6718
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12857669-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number12857669-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: