Provider Demographics
NPI:1235861022
Name:SANBORN, NATHAN (PA)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:SANBORN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-5015
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:555 W SR 164
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:UT
Practice Address - Zip Code:84653-8465
Practice Address - Country:US
Practice Address - Phone:801-465-4896
Practice Address - Fax:801-465-3267
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT13074268-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program