Healthcare Provider Details

I. General information

NPI: 1487056339
Provider Name (Legal Business Name): MICHAEL RASMUSSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W 1400 S
GARLAND UT
84312-9100
US

IV. Provider business mailing address

300 W 1400 S
GARLAND UT
84312-9100
US

V. Phone/Fax

Practice location:
  • Phone: 435-257-3684
  • Fax: 435-257-7554
Mailing address:
  • Phone: 801-360-3662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number729798-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: