Healthcare Provider Details

I. General information

NPI: 1023253754
Provider Name (Legal Business Name): TYSON ANDERSON CLUFF PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2008
Last Update Date: 05/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 N 500 E
LOGAN UT
84341-2400
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 435-716-2800
  • Fax:
Mailing address:
  • Phone: 435-716-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8256806-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-784
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: