Provider Demographics
NPI:1508506189
Name:ANDERSON, MICHAEL DAVID
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
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 1:928 E SAPPHIRE HILL WAY
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-1629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:928 E SAPPHIRE HILL WAY
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-1629
Practice Address - Country:US
Practice Address - Phone:801-641-1579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-31
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program