Provider Demographics
NPI:1043830128
Name:LOERTSCHER, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:LOERTSCHER
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 1:5720 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:STANSBURY PK
Mailing Address - State:UT
Mailing Address - Zip Code:84074-7415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5720 CANAL ST
Practice Address - Street 2:
Practice Address - City:STANSBURY PK
Practice Address - State:UT
Practice Address - Zip Code:84074-7415
Practice Address - Country:US
Practice Address - Phone:435-840-8692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8250599-4409363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily