Facts
- Status
- A
- Credential
- PA
- Type
- Individual
- Enumeration date
- 2009-10-23
- Last updated
- 2009-10-23
Specialties
Licenses
- License UT
- 4893858-1206
Location
- Practice location
- 355 N MAIN ST
- City
- KANAB UT
- Postal code
- 847413260
- Phone
- 435-644-4179
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.