Healthcare Provider Details

I. General information

NPI: 1639529555
Provider Name (Legal Business Name): MATTHEW D. SANDERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 RIVER PARK DR STE 200
PROVO UT
84604-5793
US

IV. Provider business mailing address

280 RIVER PARK DR STE 200
PROVO UT
84604-5793
US

V. Phone/Fax

Practice location:
  • Phone: 801-223-4860
  • Fax:
Mailing address:
  • Phone: 801-223-4860
  • Fax: 801-371-8993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number12238992-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: