Healthcare Provider Details

I. General information

NPI: 1750079489
Provider Name (Legal Business Name): ERIK EDLUND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 S WAKARA WAY
SALT LAKE CITY UT
84108-1244
US

IV. Provider business mailing address

421 S WAKARA WAY
SALT LAKE CITY UT
84108-1244
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax:
Mailing address:
  • Phone: 385-539-4515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14265107-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: