Provider Demographics
NPI:1487643011
Name:VASTARDIS, KAREN S (FNP)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:S
Last Name:VASTARDIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 HARRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4303
Mailing Address - Country:US
Mailing Address - Phone:801-475-3000
Mailing Address - Fax:801-475-3414
Practice Address - Street 1:1159 E 12TH ST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-5144
Practice Address - Country:US
Practice Address - Phone:801-475-3700
Practice Address - Fax:801-475-3701
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT344892-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP08185Medicare UPIN