Provider Demographics
NPI:1659248953
Name:IDOM, KYRSTANNE KAYE (PA)
Entity type:Individual
Prefix:
First Name:KYRSTANNE
Middle Name:KAYE
Last Name:IDOM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 S TAWNY DR
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84029-5028
Mailing Address - Country:US
Mailing Address - Phone:801-580-9139
Mailing Address - Fax:
Practice Address - Street 1:228 S TAWNY DR
Practice Address - Street 2:
Practice Address - City:GRANTSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84029-5028
Practice Address - Country:US
Practice Address - Phone:801-580-9139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-21
Last Update Date:2025-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant