Healthcare Provider Details

I. General information

NPI: 1730654526
Provider Name (Legal Business Name): AMANDA RENA MATSUURA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 ROUND VALLEY DR STE 201
PARK CITY UT
84060-7549
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 435-649-7680
  • Fax: 435-776-9353
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10994220-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number109942204405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: