Provider Demographics
NPI:1992221980
Name:STEPHENS, KIRK RONALD (PA-C)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:RONALD
Last Name:STEPHENS
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 1:166 E 5900 S STE B111
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7293
Mailing Address - Country:US
Mailing Address - Phone:801-268-9672
Mailing Address - Fax:
Practice Address - Street 1:7396 S UNION PARK AVE STE 201
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-6702
Practice Address - Country:US
Practice Address - Phone:801-567-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10476224-1206207N00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical