Healthcare Provider Details

I. General information

NPI: 1306975701
Provider Name (Legal Business Name): KEVIN L STUCKI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2007
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HOSPITAL LN
AFTON WY
83110-9409
US

IV. Provider business mailing address

PO BOX 280
AFTON WY
83110-0280
US

V. Phone/Fax

Practice location:
  • Phone: 307-885-5870
  • Fax: 307-885-4898
Mailing address:
  • Phone: 78-855-8703
  • Fax: 78-854-8983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number6548822-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: