Provider Demographics
NPI:1952780728
Name:ANDERSON, KILEY GLENN (RT(R)(N)(VI) CNMT)
Entity Type:Individual
Prefix:MR
First Name:KILEY
Middle Name:GLENN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:RT(R)(N)(VI) CNMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 E BRYAN AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-1713
Mailing Address - Country:US
Mailing Address - Phone:740-350-6281
Mailing Address - Fax:
Practice Address - Street 1:439 BRYAN AVENUE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115
Practice Address - Country:US
Practice Address - Phone:740-350-6281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7906934-54012471V0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471V0106XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular-Interventional Technology