Provider Demographics
NPI:1275647489
Name:KILLPACK, JOHN R (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:KILLPACK
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 1:2174 N CLIFFROSE CIR
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-7765
Mailing Address - Country:US
Mailing Address - Phone:435-531-6668
Mailing Address - Fax:
Practice Address - Street 1:1303 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-9746
Practice Address - Country:US
Practice Address - Phone:801-993-9501
Practice Address - Fax:801-733-5618
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT201807-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT597854OtherHEALTHY U
UT2000630OtherUNITED HEALTHCARE
UT851396OtherDESERET MUTUAL
AZ943284Medicaid
UTTPRA09124OtherMOLINA
UT107026813102OtherIHC
UT79799OtherPEHP
UT597854OtherHEALTHY U
AZ943284Medicaid