Provider Demographics
NPI:1861962912
Name:RUNDELL, TYLER J (PA-C)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:J
Last Name:RUNDELL
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 1:4325 S DOREEN CIR
Mailing Address - Street 2:
Mailing Address - City:MILLCREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2816
Mailing Address - Country:US
Mailing Address - Phone:607-316-3109
Mailing Address - Fax:
Practice Address - Street 1:585 MAIN ST
Practice Address - Street 2:
Practice Address - City:GREEN RIVER
Practice Address - State:UT
Practice Address - Zip Code:84525
Practice Address - Country:US
Practice Address - Phone:435-564-3434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10877596-8906363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10877596-1206OtherUTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING
UT10877596-8906OtherUTAH DIVISION OF OCCUPATIONAL AND PROFESSIONAL LICENSING
1152696OtherNATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS