1720302680 NPI number — KRISTINE S HERLEVI PA-C

Table of content: KRISTINE S HERLEVI PA-C (NPI 1720302680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720302680 NPI number — KRISTINE S HERLEVI PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERLEVI
Provider First Name:
KRISTINE
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

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:
1720302680
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
470 E 3900 S
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84107-2332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-747-2800
Provider Business Mailing Address Fax Number:
801-747-5222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2839 ST ROSE PKWY
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89052-4806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-837-8988
Provider Business Practice Location Address Fax Number:
702-990-5269
Provider Enumeration Date:
03/22/2010

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: 363A00000X , with the licence number:  8322950-1206 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AM0700X , with the licence number: PA1211 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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