Provider Demographics
NPI:1992779185
Name:KILLEN, AMY B (MD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:B
Last Name:KILLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12340 S 450 E
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8154
Mailing Address - Country:US
Mailing Address - Phone:801-501-9797
Mailing Address - Fax:801-501-9799
Practice Address - Street 1:12340 S 450 E
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8154
Practice Address - Country:US
Practice Address - Phone:801-501-9797
Practice Address - Fax:801-501-9799
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33810207P00000X
UT9140981-1205208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ947509Medicaid
AZ947509Medicaid
106991Medicare ID - Type Unspecified