Provider Demographics
NPI:1104203249
Name:KUPFER, JEFFRY K (CRNA)
Entity Type:Individual
Prefix:
First Name:JEFFRY
Middle Name:K
Last Name:KUPFER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1682 TEMPLE CT
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-1508
Mailing Address - Country:US
Mailing Address - Phone:435-559-1387
Mailing Address - Fax:
Practice Address - Street 1:3000 N TRIUMPH BLVD
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043
Practice Address - Country:US
Practice Address - Phone:385-345-3000
Practice Address - Fax:770-701-6676
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000384163W00000X, 367500000X
UT7640423-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1104203249Medicare NSC