Healthcare Provider Details

I. General information

NPI: 1841854338
Provider Name (Legal Business Name): TANDY MUSE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4460 S HIGHLAND DR STE 400
SALT LAKE CITY UT
84124-3565
US

IV. Provider business mailing address

4460 S HIGHLAND DR STE 400
SALT LAKE CITY UT
84124-3565
US

V. Phone/Fax

Practice location:
  • Phone: 801-272-4111
  • Fax: 801-272-5989
Mailing address:
  • Phone: 801-272-4111
  • Fax: 801-272-5989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11281903-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: