Provider Demographics
NPI:1619398021
Name:LUNDBERG, BRYAN WILLIAM (PA-C)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:WILLIAM
Last Name:LUNDBERG
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:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-954-7672
Mailing Address - Fax:801-492-2235
Practice Address - Street 1:4071 S 4000 W
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-4143
Practice Address - Country:US
Practice Address - Phone:801-265-0103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-02
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
UT8905020-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant