Healthcare Provider Details

I. General information

NPI: 1134568850
Provider Name (Legal Business Name): EMILY MARIE ANDERSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2013
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4403 HARRISON BLVD STE 3490
OGDEN UT
84403-3284
US

IV. Provider business mailing address

10351 DAWSONS CREEK BLVD SUITE A-1
FORT WAYNE IN
46825-1904
US

V. Phone/Fax

Practice location:
  • Phone: 801-442-3256
  • Fax:
Mailing address:
  • Phone: 260-203-9600
  • Fax: 260-739-6167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001527A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001527A
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: