Provider Demographics
NPI:1831475748
Name:KUSHMAN, LANGLEY L (PA)
Entity Type:Individual
Prefix:
First Name:LANGLEY
Middle Name:L
Last Name:KUSHMAN
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 1:127 S 500 E
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1959
Mailing Address - Country:US
Mailing Address - Phone:801-587-6336
Mailing Address - Fax:
Practice Address - Street 1:175 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-5901
Practice Address - Country:US
Practice Address - Phone:801-587-6336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-25
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
UT9316490-1206363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant