Provider Demographics
NPI:1164440665
Name:SANDBERG, EMILY E (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:E
Last Name:SANDBERG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 W. 300 N.
Mailing Address - Street 2:STE A
Mailing Address - City:WEST POINT
Mailing Address - State:UT
Mailing Address - Zip Code:84015
Mailing Address - Country:US
Mailing Address - Phone:801-614-5140
Mailing Address - Fax:801-614-5144
Practice Address - Street 1:3110 W. 300 N.
Practice Address - Street 2:STE A
Practice Address - City:WEST POINT
Practice Address - State:UT
Practice Address - Zip Code:84015
Practice Address - Country:US
Practice Address - Phone:801-614-5140
Practice Address - Fax:801-614-5144
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT60220351206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q55919Medicare UPIN
UT005535934Medicare ID - Type Unspecified