Healthcare Provider Details

I. General information

NPI: 1578749123
Provider Name (Legal Business Name): WADE MOYLE ANDERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 N 100 E
GUNNISON UT
84634-7720
US

IV. Provider business mailing address

PO BOX 849 SUITE A
GUNNISON UT
84634-0849
US

V. Phone/Fax

Practice location:
  • Phone: 435-528-7202
  • Fax: 435-528-3624
Mailing address:
  • Phone: 435-528-7202
  • Fax: 435-528-3624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6817642-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: