MEDICARE: BRYAN WILLIAM LUNDBERG 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	363A00000X	Physician Assistant
2	363A00000X	Physician Assistant	8905020-1206	UT

General Provider Information

NPI Number	:	1619398021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYAN WILLIAM LUNDBERG PA-C

Provider Business Mailing Address
First Line	:	PO BOX 35380
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89133-5380
Country	:	US
Telephone Number	:	702-954-7672
Fax Number	:	801-492-2235

Provider Business Practice Location Address
First Line	:	4071 S 4000 W
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84120-4143
Country	:	US
Telephone Number	:	801-265-0103
Fax Number	:

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

Provider Enumeration Date	:	01/02/2014
Last Update Date	:	06/07/2024

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