Healthcare Provider Details

I. General information

NPI: 1750619052
Provider Name (Legal Business Name): BRIAN M MATTHEWS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2009
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 N 1100 E
AMERICAN FORK UT
84003-2096
US

IV. Provider business mailing address

891 E 280 N
OREM UT
84097-4991
US

V. Phone/Fax

Practice location:
  • Phone: 801-310-4888
  • Fax:
Mailing address:
  • Phone: 801-310-4888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number6203510-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: