Healthcare Provider Details

I. General information

NPI: 1609404409
Provider Name (Legal Business Name): MONTANA WYNN GUBRUD PA-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2020
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5911 S FASHION BLVD STE 200
MURRAY UT
84107-7210
US

IV. Provider business mailing address

5911 S FASHION BLVD STE 200
MURRAY UT
84107-7210
US

V. Phone/Fax

Practice location:
  • Phone: 385-525-3270
  • Fax:
Mailing address:
  • Phone: 385-525-3270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14289197-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: