Provider Demographics
NPI:1932616695
Name:CROCKETT, KEVIN JAMES
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JAMES
Last Name:CROCKETT
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 1:30 E HUNTERS HVN
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:UT
Mailing Address - Zip Code:84045-8169
Mailing Address - Country:US
Mailing Address - Phone:801-400-9616
Mailing Address - Fax:
Practice Address - Street 1:30 E HUNTERS HVN
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:UT
Practice Address - Zip Code:84045-8169
Practice Address - Country:US
Practice Address - Phone:801-400-9616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10620174-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant