Provider Demographics
NPI:1114654027
Name:KORDSIEMON, GARRETT
Entity type:Individual
Prefix:
First Name:GARRETT
Middle Name:
Last Name:KORDSIEMON
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 1:15229 S TACK WAY
Mailing Address - Street 2:
Mailing Address - City:BLUFFDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84065-1798
Mailing Address - Country:US
Mailing Address - Phone:801-503-6302
Mailing Address - Fax:
Practice Address - Street 1:1500 N RENAISSANCE BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-7002
Practice Address - Country:US
Practice Address - Phone:505-266-5565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9374356-1206363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program