Provider Demographics
NPI:1326292210
Name:LOVERIDGE, KEVIN C (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:LOVERIDGE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 N 2200 W
Mailing Address - Street 2:UTAH AIR NATIONAL GUARD / 151 MDG
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-2926
Mailing Address - Country:US
Mailing Address - Phone:801-245-2190
Mailing Address - Fax:
Practice Address - Street 1:765 N 2200 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-2926
Practice Address - Country:US
Practice Address - Phone:801-245-2190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2025-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7151945-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000066264Medicare PIN