Provider Demographics
NPI:1578820445
Name:SANDYGREN, NOLAN (MD)
Entity Type:Individual
Prefix:
First Name:NOLAN
Middle Name:
Last Name:SANDYGREN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4946 W 6200 S
Mailing Address - Street 2:
Mailing Address - City:KEARNS
Mailing Address - State:UT
Mailing Address - Zip Code:84118-6703
Mailing Address - Country:US
Mailing Address - Phone:801-871-4444
Mailing Address - Fax:801-871-4494
Practice Address - Street 1:4946 W 6200 S
Practice Address - Street 2:
Practice Address - City:KEARNS
Practice Address - State:UT
Practice Address - Zip Code:84118-6703
Practice Address - Country:US
Practice Address - Phone:801-871-4444
Practice Address - Fax:801-871-4494
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8790918-1205207Q00000X
UT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty