Provider Demographics
NPI:1811624513
Name:MCKINNON, KATIE ELAINE RIDGE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:ELAINE RIDGE
Last Name:MCKINNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1281 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3622
Mailing Address - Country:US
Mailing Address - Phone:909-915-4077
Mailing Address - Fax:
Practice Address - Street 1:1900 N STATE ST STE 105
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1354
Practice Address - Country:US
Practice Address - Phone:801-655-5245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2023-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13072448-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant