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General NPI Number Information
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NPI Number | 1831826759
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Entity Type | Individual
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Provider Name | KEVIN MARK ANDERSON PA-C
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Gender | Male
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Dates
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Enumeration Date | 08/02/2022
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Last Update Date | 02/06/2023
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Provider Practice Location Address
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Address Line | 4403 HARRISON BLVD STE 3815
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City | OGDEN
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State | UT
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Zip | 84403-3330
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Country | US
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Telephone | 801-387-5620
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 27128
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City | SALT LAKE CITY
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State | UT
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Zip | 84127-0128
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Country | US
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Telephone | 801-387-5620
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Fax |
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 9717755-1206
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License Number State | UT
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