Provider Demographics
NPI:1063663540
Name:ANDERSON, PAUL D (MPT)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:D
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 W MAIN STREET CT STE 100
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:UT
Mailing Address - Zip Code:84004-5602
Mailing Address - Country:US
Mailing Address - Phone:801-216-4298
Mailing Address - Fax:801-216-4298
Practice Address - Street 1:75 W MAIN STREET CT STE 100
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:UT
Practice Address - Zip Code:84004-5602
Practice Address - Country:US
Practice Address - Phone:801-216-4298
Practice Address - Fax:801-216-4298
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4777580-24012251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic