Healthcare Provider Details

I. General information

NPI: 1962022780
Provider Name (Legal Business Name): ANDREW GUBLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 W 2600 S
BOUNTIFUL UT
84010-7717
US

IV. Provider business mailing address

233 N HOUSTON RD STE 140E
WARNER ROBINS GA
31093-3023
US

V. Phone/Fax

Practice location:
  • Phone: 801-298-9155
  • Fax: 801-298-9156
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13212001-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: