Healthcare Provider Details

I. General information

NPI: 1265803837
Provider Name (Legal Business Name): ANDREW STRADLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2015
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

776 N TERMINAL DR
SALT LAKE CITY UT
84122-7003
US

IV. Provider business mailing address

9508 S TARBERT CIR
SOUTH JORDAN UT
84009-9733
US

V. Phone/Fax

Practice location:
  • Phone: 801-995-0366
  • Fax:
Mailing address:
  • Phone: 801-995-0366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number9106894-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: