=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063663540
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL D. ANDERSON MPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2008
-----------------------------------------------------
Last Update Date | 10/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 75 W MAIN STREET CT STE 100
-----------------------------------------------------
City | ALPINE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84004-5602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-216-4298
-----------------------------------------------------
Fax | 801-216-4298
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 75 W MAIN STREET CT STE 100
-----------------------------------------------------
City | ALPINE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84004-5602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-216-4298
-----------------------------------------------------
Fax | 801-216-4298
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 4777580-2401
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------