Provider Demographics
NPI:1962251819
Name:GOUE, KEAN GIRESSE
Entity type:Individual
Prefix:
First Name:KEAN
Middle Name:GIRESSE
Last Name:GOUE
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 1:177 W PRICE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-4345
Mailing Address - Country:US
Mailing Address - Phone:801-503-4369
Mailing Address - Fax:
Practice Address - Street 1:177 W PRICE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-4345
Practice Address - Country:US
Practice Address - Phone:801-503-4369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTF24-112840175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist