Provider Demographics
NPI:1659721934
Name:GUNDERSEN, SHAUN (DNP, APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:GUNDERSEN
Suffix:
Gender:M
Credentials:DNP, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 S SR 112 HWY STE 106
Mailing Address - Street 2:
Mailing Address - City:GRANTSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84029-5520
Mailing Address - Country:US
Mailing Address - Phone:435-264-4164
Mailing Address - Fax:435-264-4264
Practice Address - Street 1:163 S SR 112 HWY STE 106
Practice Address - Street 2:
Practice Address - City:GRANTSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84029-5520
Practice Address - Country:US
Practice Address - Phone:435-264-4164
Practice Address - Fax:435-264-4264
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8635933-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1073795258Medicaid