Provider Demographics
NPI:1487056339
Name:RASMUSSEN, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:RASMUSSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W 1400 S
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84312-9100
Mailing Address - Country:US
Mailing Address - Phone:801-360-3662
Mailing Address - Fax:
Practice Address - Street 1:300 W 1400 S
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:UT
Practice Address - Zip Code:84312-9100
Practice Address - Country:US
Practice Address - Phone:435-257-3684
Practice Address - Fax:435-257-7554
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-23
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT729798-4405363L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty