Provider Demographics
NPI:1316620131
Name:SUDBURY, IAN TAYLOR (PA-C)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:TAYLOR
Last Name:SUDBURY
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 1:5018 W GREAT BASIN CIR
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-1846
Mailing Address - Country:US
Mailing Address - Phone:801-699-8660
Mailing Address - Fax:
Practice Address - Street 1:5018 W GREAT BASIN CIR
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096-1846
Practice Address - Country:US
Practice Address - Phone:801-699-8660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant