Provider Demographics
NPI:1609818137
Name:NYDEGGER, DAVID AARON (PA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:AARON
Last Name:NYDEGGER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:AARON
Other - Last Name:NYDGGER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:390 N MAIN
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010
Mailing Address - Country:US
Mailing Address - Phone:208-359-0901
Mailing Address - Fax:208-359-0928
Practice Address - Street 1:54 N 800 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-3326
Practice Address - Country:US
Practice Address - Phone:208-359-0901
Practice Address - Fax:208-359-0928
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-541363A00000X
UT5710346-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807155200Medicaid
ID1666931Medicare ID - Type Unspecified
IDQ41789Medicare UPIN