Provider Demographics
NPI:1154065969
Name:ANDERSON, MICHAEL WESLEY
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WESLEY
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 W 410 S
Mailing Address - Street 2:SUITE #110
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663
Mailing Address - Country:US
Mailing Address - Phone:801-477-4084
Mailing Address - Fax:
Practice Address - Street 1:815 W 410 S
Practice Address - Street 2:SUITE #110
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663
Practice Address - Country:US
Practice Address - Phone:801-477-4084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program