MEDICARE: KIAH LYNN CARDENAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	54827	CA
2	363AM0700X	Medical Physician Assistant	54827	CA
3	363AS0400X	Surgical Physician Assistant	54827	CA
4	363A00000X	Physician Assistant	13676616-1206	UT

General Provider Information

NPI Number	:	1144747403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIAH LYNN CARDENAS

Provider Business Mailing Address
First Line	:	1662 S WOLVERINE WAY
Second Line	:
City	:	WASHINGTON
State	:	UT
Zip	:	84780-3638
Country	:	US
Telephone Number	:	530-613-4662
Fax Number	:

Provider Business Practice Location Address
First Line	:	218 HOWLE AVE
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29412-2449
Country	:	US
Telephone Number	:	833-225-3558
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2017
Last Update Date	:	07/17/2024

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