Healthcare Provider Details

I. General information

NPI: 1689330847
Provider Name (Legal Business Name): TYSON RAY FERNSTROM DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2021
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4095 E PONY EXPRESS PWKY STE 6
EAGLE MOUNTAIN UT
84005
US

IV. Provider business mailing address

4095 E PONY EXPRESS PWKY STE 6
EAGLE MOUNTAIN UT
84005
US

V. Phone/Fax

Practice location:
  • Phone: 801-459-7545
  • Fax:
Mailing address:
  • Phone: 801-459-7545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14282651-2401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: