Healthcare Provider Details

I. General information

NPI: 1770513095
Provider Name (Legal Business Name): WASATCH NEONATAL LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 W 800 N
OREM UT
84057-3660
US

IV. Provider business mailing address

730 W 800 N STE 340B
OREM UT
84057-6300
US

V. Phone/Fax

Practice location:
  • Phone: 801-655-5425
  • Fax: 801-655-5426
Mailing address:
  • Phone: 801-655-5425
  • Fax: 801-655-5426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number2210714405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number184816-1205
License Number StateUT

VIII. Authorized Official

Name: DR. DALE R GERSTMANN
Title or Position: EXECUTIVE DIRECTOR
Credential: M.D.
Phone: 801-655-5425