Provider Demographics
NPI:1689304628
Name:THURBER, KRISTAN
Entity Type:Individual
Prefix:MRS
First Name:KRISTAN
Middle Name:
Last Name:THURBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6405 S 3000 E STE 300
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6977
Mailing Address - Country:US
Mailing Address - Phone:208-351-2945
Mailing Address - Fax:
Practice Address - Street 1:3360 WASHINGTON PKWY STE 2
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8333
Practice Address - Country:US
Practice Address - Phone:208-932-7024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-2690363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant