Healthcare Provider Details

I. General information

NPI: 1003306473
Provider Name (Legal Business Name): PETER MICHAEL SUNDWALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2018
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10290 N. NORTH COUNTY BLVD. STE 200
HIGHLAND UT
84003-8400
US

IV. Provider business mailing address

10290 N NORTH COUNTY BLVD STE 200
HIGHLAND UT
84003-8973
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-6000
  • Fax: 208-625-6001
Mailing address:
  • Phone: 801-899-3391
  • Fax: 801-685-3266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12158239-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: