Provider Demographics
NPI:1801884614
Name:TRUNNELL, MARTHA (PA)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:TRUNNELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1756 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-4701
Mailing Address - Country:US
Mailing Address - Phone:801-254-0309
Mailing Address - Fax:801-254-1012
Practice Address - Street 1:516 E. NIZHONI BLVD.
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-722-1705
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT104839-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant