Healthcare Provider Details

I. General information

NPI: 1508788662
Provider Name (Legal Business Name): FST PHYSICAL THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2026
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:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. TYSON FERNSTROM
Title or Position: PHYSICAL THERAPIST/OWNER
Credential: PT, DPT
Phone: 801-459-7545