Provider Demographics
NPI:1689308744
Name:PETERSON, KEVIN LYMAN (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LYMAN
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 W MARINWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-4369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1325 W MARINWOOD AVE
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-4369
Practice Address - Country:US
Practice Address - Phone:801-678-1137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12857669-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant