Healthcare Provider Details

I. General information

NPI: 1134101546
Provider Name (Legal Business Name): STEPHEN TIMOTHY ANDERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2005
Last Update Date: 02/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 E MAIN ST
LEHI UT
84043-2241
US

IV. Provider business mailing address

680 E MAIN ST
LEHI UT
84043-2241
US

V. Phone/Fax

Practice location:
  • Phone: 801-768-8800
  • Fax: 801-820-8200
Mailing address:
  • Phone: 801-768-8800
  • Fax: 801-820-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number6938867-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: