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General NPI Number Information
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NPI Number | 1861962912
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Entity Type | Individual
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Provider Name | TYLER J RUNDELL PA-C
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Gender | Male
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Dates
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Enumeration Date | 12/03/2018
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Last Update Date | 12/03/2018
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Provider Practice Location Address
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Address Line | 585 MAIN ST
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City | GREEN RIVER
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State | UT
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Zip | 84525
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Country | US
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Telephone | 435-564-3434
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Fax |
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Provider Business Mailing Address
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Address Line | 4325 S DOREEN CIR
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City | MILLCREEK
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State | UT
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Zip | 84107-2816
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Country | US
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Telephone | 607-316-3109
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 10877596-8906
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License Number State | UT
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