Provider Demographics
NPI:1518959535
Name:PACKER, KRAIG LYNN (NPC)
Entity Type:Individual
Prefix:MR
First Name:KRAIG
Middle Name:LYNN
Last Name:PACKER
Suffix:
Gender:M
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3339 CHEROKEE LN
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4866
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3339 CHEROKEE LN
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4866
Practice Address - Country:US
Practice Address - Phone:801-803-0877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT261539-4405363L00000X, 363LA2200X
CO115014363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO50634879Medicaid
Q04792Medicare UPIN
COC519448Medicare ID - Type Unspecified