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General NPI Number Information
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NPI Number | 1306635818
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Entity Type | Organization
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Legal Business Name | DERMATOLOGY WEST LLC
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Dates
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Enumeration Date | 05/01/2025
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Last Update Date | 05/01/2025
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Provider Practice Location Address
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Address Line | 1741 N 2000 W STE 3
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City | FARR WEST
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State | UT
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Zip | 84404-9811
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Country | US
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Telephone | 801-917-6177
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Fax | 801-917-5688
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Provider Business Mailing Address
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Address Line | 1741 N 2000 W STE 3
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City | FARR WEST
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State | UT
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Zip | 84404-9811
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Country | US
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Telephone | 801-917-6177
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Fax | 801-917-5688
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Authorized Official
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Title or Position | OWNER
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Name | TYLER JORDAN MCKINNON
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Credential | PA-C
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Telephone | 801-866-6753
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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