1275647489 NPI number — JOHN R KILLPACK CRNA

Table of content: JOHN R KILLPACK CRNA (NPI 1275647489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275647489 NPI number — JOHN R KILLPACK CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILLPACK
Provider First Name:
JOHN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275647489
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2174 N CLIFFROSE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAR CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84720-7765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-531-6668
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1303 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CEDAR CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84720-9746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-993-9501
Provider Business Practice Location Address Fax Number:
801-733-5618
Provider Enumeration Date:
08/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  201807-4406 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 597854 . This is a "HEALTHY U" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 2000630 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 851396 . This is a "DESERET MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 943284 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: TPRA09124 . This is a "MOLINA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107026813102 . This is a "IHC" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 79799 . This is a "PEHP" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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