Healthcare Provider Details

I. General information

NPI: 1417500158
Provider Name (Legal Business Name): DAVID ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2376 N 400 E STE 102
TOOELE UT
84074-3413
US

IV. Provider business mailing address

1455 S 500 W STE B
BOUNTIFUL UT
84010-8252
US

V. Phone/Fax

Practice location:
  • Phone: 435-843-1225
  • Fax:
Mailing address:
  • Phone: 801-784-2111
  • Fax: 844-670-1991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: