Provider Demographics
NPI:1417525544
Name:BERTOCH, SAMUEL MARK (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:MARK
Last Name:BERTOCH
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2750 NORTH 2762 WEST
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066
Mailing Address - Country:US
Mailing Address - Phone:435-722-9250
Mailing Address - Fax:
Practice Address - Street 1:2750 NORTH 2762 WEST
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066
Practice Address - Country:US
Practice Address - Phone:435-722-9250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT327174-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner