Provider Demographics
NPI:1568423879
Name:PINNA, KENNETH R (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:PINNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 S 300 E STE 101
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-3931
Mailing Address - Country:US
Mailing Address - Phone:435-688-1128
Mailing Address - Fax:435-673-4045
Practice Address - Street 1:515 S 300 E, STE 101
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3900
Practice Address - Country:US
Practice Address - Phone:435-688-1128
Practice Address - Fax:435-673-4045
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT541616501205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT9385678OtherPRIVATE HEALTH CARE SYSTE
UT0200037OtherUNITED HEALTH CARE
UT81217OtherPUBLIC EMPLOYEES HEALTH P
UT107023322102OtherINTERMOUNTAIN HEALTH CARE
UT233306OtherALTIUS
UT1568423879Medicaid
UT200355426KRPOtherEDUCATORS MUTUAL
UT7358374OtherAETNA
UT54161501202001OtherBLUE CROSS/ BLUE SHIELD
UT5595330OtherFIRST HEALTH
UT005784301Medicare ID - Type Unspecified
UT1568423879Medicaid