Provider Demographics
NPI:1194088856
Name:THURSTON, MCKENNAN J (MD)
Entity type:Individual
Prefix:
First Name:MCKENNAN
Middle Name:J
Last Name:THURSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4166 SUMMER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MORGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84050-9344
Mailing Address - Country:US
Mailing Address - Phone:801-809-3766
Mailing Address - Fax:801-516-0639
Practice Address - Street 1:4166 SUMMER RIDGE RD
Practice Address - Street 2:
Practice Address - City:MORGAN
Practice Address - State:UT
Practice Address - Zip Code:84050-9344
Practice Address - Country:US
Practice Address - Phone:801-809-3766
Practice Address - Fax:801-516-0639
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN56747207Q00000X
UT9817986-1205207QS0010X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400100888Medicare PIN