Basic Information
| Provider Information | |||||||||
| NPI: | 1275647489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KILLPACK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2174 N CLIFFROSE CIR | ||||||||
| Address2: | |||||||||
| City: | CEDAR CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847207765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4355316668 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1303 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CEDAR CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847209746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019939501 | ||||||||
| FaxNumber: | 8017335618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 201807-4406 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 597854 | 01 | UT | HEALTHY U | OTHER | 2000630 | 01 | UT | UNITED HEALTHCARE | OTHER | 851396 | 01 | UT | DESERET MUTUAL | OTHER | 943284 | 05 | AZ | MEDICAID | TPRA09124 | 01 | UT | MOLINA | OTHER | 107026813102 | 01 | UT | IHC | OTHER | 79799 | 01 | UT | PEHP | OTHER |