Healthcare Provider Details

I. General information

NPI: 1861962912
Provider Name (Legal Business Name): TYLER J RUNDELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2018
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 MAIN ST
GREEN RIVER UT
84525
US

IV. Provider business mailing address

4325 S DOREEN CIR
MILLCREEK UT
84107-2816
US

V. Phone/Fax

Practice location:
  • Phone: 435-564-3434
  • Fax:
Mailing address:
  • Phone: 607-316-3109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10877596-8906
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: