Healthcare Provider Details

I. General information

NPI: 1134990674
Provider Name (Legal Business Name): SKYLER GERDES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2024
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

905 E FENCE POST RD
FRUIT HEIGHTS UT
84037-6785
US

V. Phone/Fax

Practice location:
  • Phone: 801-543-9041
  • Fax:
Mailing address:
  • Phone: 801-543-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number13760498-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number266108
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: