Provider Demographics
NPI:1508306168
Name:TUPUOLA, KAWIKA
Entity type:Individual
Prefix:
First Name:KAWIKA
Middle Name:
Last Name:TUPUOLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6013 S REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123-5220
Mailing Address - Country:US
Mailing Address - Phone:801-255-5131
Mailing Address - Fax:801-255-5131
Practice Address - Street 1:1841 E RIVERSIDE DR STE 201
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-7061
Practice Address - Country:US
Practice Address - Phone:435-256-8890
Practice Address - Fax:833-907-2388
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-01
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
UT363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No101Y00000XBehavioral Health & Social Service ProvidersCounselor