MEDICARE: MRS. EMILY E. SANDBERG PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	60220351206	UT

General Provider Information

NPI Number	:	1164440665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. EMILY E. SANDBERG PA-C

Provider Business Mailing Address
First Line	:	3110 W. 300 N.
Second Line	:	STE A
City	:	WEST POINT
State	:	UT
Zip	:	84015
Country	:	US
Telephone Number	:	801-614-5140
Fax Number	:	801-614-5144

Provider Business Practice Location Address
First Line	:	3110 W. 300 N.
Second Line	:	STE A
City	:	WEST POINT
State	:	UT
Zip	:	84015
Country	:	US
Telephone Number	:	801-614-5140
Fax Number	:	801-614-5144

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	09/03/2009

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