Provider Demographics
NPI:1831290790
Name:CHRISTENSEN, KYLE J (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:J
Last Name:CHRISTENSEN
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 1:1000 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84701-2061
Mailing Address - Country:US
Mailing Address - Phone:435-893-0800
Mailing Address - Fax:
Practice Address - Street 1:1000 N MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-2069
Practice Address - Country:US
Practice Address - Phone:435-893-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2006-0022363AS0400X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM47589523Medicaid
NMPA2006-0022OtherMEDICAL LICENSE
NM47589523Medicaid
NMPA2006-0022OtherMEDICAL LICENSE