Healthcare Provider Details

I. General information

NPI: 1801564448
Provider Name (Legal Business Name): DALLIN PETERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5169 S COTTONWOOD ST STE 640
MURRAY UT
84107-6771
US

IV. Provider business mailing address

11201 BENTON ST
LOMA LINDA CA
92357-1000
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-3600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61843
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14172614-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: