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General NPI Number Information
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NPI Number | 1194088856
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Entity Type | Individual
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Provider Name | MCKENNAN J. THURSTON MD
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Gender | Male
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Dates
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Enumeration Date | 06/19/2012
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Last Update Date | 04/17/2024
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Provider Practice Location Address
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Address Line | 4166 SUMMER RIDGE RD
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City | MORGAN
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State | UT
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Zip | 84050-9344
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Country | US
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Telephone | 801-809-3766
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Fax | 801-516-0639
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Provider Business Mailing Address
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Address Line | 4166 SUMMER RIDGE RD
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City | MORGAN
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State | UT
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Zip | 84050-9344
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Country | US
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Telephone | 801-809-3766
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Fax | 801-516-0639
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 56747
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number | 9817986-1205
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License Number State | UT
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