Individual
TYLER J RUNDELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
585 MAIN ST, GREEN RIVER, UT 84525
(435) 564-3434
Mailing address
4325 S DOREEN CIR, MILLCREEK, UT 84107-2816
(607) 316-3109
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
10877596-8906
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10877596-1206
UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING
UT
01
—
10877596-8906
UTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING
UT
01
—
1152696
NATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS
—
Enumeration date
12/03/2018
Last updated
12/03/2018
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