Healthcare Provider Details

I. General information

NPI: 1972360329
Provider Name (Legal Business Name): CALEB SANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S 1000 E
SALT LAKE CITY UT
84102-1443
US

IV. Provider business mailing address

562 E BROWNING AVE
SALT LAKE CITY UT
84105-2025
US

V. Phone/Fax

Practice location:
  • Phone: 801-823-1988
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: