Provider Demographics
NPI:1366111601
Name:DAHL, MITCHELL (PA-C)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:DAHL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 ROUND VALLEY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-7552
Mailing Address - Country:US
Mailing Address - Phone:435-655-6607
Mailing Address - Fax:
Practice Address - Street 1:39000 BOB HOPE DRIVE, HARRY AND DIANE RINKER BLG
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-568-2684
Practice Address - Fax:760-341-5832
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8772001206363A00000X
CAPA60276363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA60276OtherMEDICAL LICENSE
UT8772001206OtherMEDICAL