Provider Demographics
NPI:1700403995
Name:ASTLE, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:ASTLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:782 CANTERBURY LN
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:UT
Mailing Address - Zip Code:84004-1255
Mailing Address - Country:US
Mailing Address - Phone:801-866-8802
Mailing Address - Fax:
Practice Address - Street 1:782 CANTERBURY LN
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:UT
Practice Address - Zip Code:84004-1255
Practice Address - Country:US
Practice Address - Phone:801-866-8802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-03
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11940162-1206363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program