Provider Demographics
NPI:1730865882
Name:WORRELL, KIERAN DAVID (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:KIERAN
Middle Name:DAVID
Last Name:WORRELL
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1091 E SAGEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84721-4457
Mailing Address - Country:US
Mailing Address - Phone:951-733-6575
Mailing Address - Fax:
Practice Address - Street 1:8432 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-3206
Practice Address - Country:US
Practice Address - Phone:951-689-5771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13199201-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty