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NPI Code Detail

MEDICARE: MS. KIMBERLY DAWN HAYCOCK PA-C

MEDICARE: MS. KIMBERLY DAWN HAYCOCK PA-C
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
1363A00000XPhysician Assistant5170865-1206UT

General Provider Information

NPI Number : 1205862208
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. KIMBERLY DAWN HAYCOCK PA-C
Provider Business Mailing Address
First Line : PO BOX 30180
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84130-0180
Country : US
Telephone Number : 485-590-1124
Fax Number :
Provider Business Practice Location Address
First Line : 1303 N MAIN ST
Second Line :
City : CEDAR CITY
State : UT
Zip : 84721-9746
Country : US
Telephone Number : 435-868-5251
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/23/2006
Last Update Date : 10/10/2016

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