Basic Information
| Provider Information | |||||||||
| NPI: | 1326533480 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COOK | ||||||||
| FirstName: | KRISTA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1552 W DUPONT AVE | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841163651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017269043 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1552 W DUPONT AVE | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841163651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017269043 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2018 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | N | Other Service Providers | Community Health Worker | 363AM0700X | 5830482-1206 | UT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | 5830482-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.