Provider Demographics
NPI:1831294784
Name:VICK, KEVIN T (CRNA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:T
Last Name:VICK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1954 FORT UNION BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3460 PIONEER PKWY
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84120-2049
Practice Address - Country:US
Practice Address - Phone:801-993-1566
Practice Address - Fax:801-733-5618
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5594772-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTTPRA09780OtherMOLINA
UT218512OtherALTIUS
UT78674OtherPEHP
UT880917OtherDESERET MUTUAL
UTP00149473Medicare ID - Type UnspecifiedRAILROAD MEDICARE
UT218512OtherALTIUS