Provider Demographics
NPI:1386441996
Name:GRUNWALD, TEGAN
Entity type:Individual
Prefix:
First Name:TEGAN
Middle Name:
Last Name:GRUNWALD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2177 S NOWELL CIR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2869
Mailing Address - Country:US
Mailing Address - Phone:541-760-0032
Mailing Address - Fax:
Practice Address - Street 1:3115 E LION LN STE 160
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121
Practice Address - Country:US
Practice Address - Phone:855-255-1750
Practice Address - Fax:855-255-0905
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-01
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12627832-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily