Provider Demographics
NPI:1306939350
Name:GOELLER, KRISTIN GALE (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:GALE
Last Name:GOELLER
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 1:6234 W MARCREST DR
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84128-1351
Mailing Address - Country:US
Mailing Address - Phone:801-647-3778
Mailing Address - Fax:
Practice Address - Street 1:5770 S 250 E STE 415
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-268-2822
Practice Address - Fax:801-268-2832
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA00110002060363AM0700X
VI15363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI0085416Medicare PIN
VI0058979Medicare PIN