Provider Demographics
NPI:1982965034
Name:BLACK, KRISTEN HAAS (DO)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:HAAS
Last Name:BLACK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-285-4700
Mailing Address - Fax:
Practice Address - Street 1:3723 W 12600 S STE 360
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7296
Practice Address - Country:US
Practice Address - Phone:801-285-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019941207V00000X
UT9732284-1204207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology