Provider Demographics
NPI:1306635818
Name:DERMATOLOGY WEST LLC
Entity type:Organization
Organization Name:DERMATOLOGY WEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:JORDAN
Authorized Official - Last Name:MCKINNON
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:801-866-6753
Mailing Address - Street 1:1741 N 2000 W STE 3
Mailing Address - Street 2:
Mailing Address - City:FARR WEST
Mailing Address - State:UT
Mailing Address - Zip Code:84404-9811
Mailing Address - Country:US
Mailing Address - Phone:801-917-6177
Mailing Address - Fax:801-917-5688
Practice Address - Street 1:1741 N 2000 W STE 3
Practice Address - Street 2:
Practice Address - City:FARR WEST
Practice Address - State:UT
Practice Address - Zip Code:84404-9811
Practice Address - Country:US
Practice Address - Phone:801-917-6177
Practice Address - Fax:801-917-5688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-01
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty