Provider Demographics
NPI:1982692000
Name:BOYER, KIMBERLY A (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:BOYER
Suffix:
Gender:F
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 1:4650 HARRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4303
Mailing Address - Country:US
Mailing Address - Phone:801-479-4621
Mailing Address - Fax:801-476-2670
Practice Address - Street 1:1159 E 12TH ST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-5144
Practice Address - Country:US
Practice Address - Phone:801-334-3000
Practice Address - Fax:801-476-2670
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2671291206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTR44681Medicare UPIN