Healthcare Provider Details

I. General information

NPI: 1215378377
Provider Name (Legal Business Name): TYLER ASHTON BRIDGEWATER FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S 400 E
BOUNTIFUL UT
84010-4933
US

IV. Provider business mailing address

976 FOXBORO DR
NORTH SALT LAKE UT
84054-6002
US

V. Phone/Fax

Practice location:
  • Phone: 801-295-2361
  • Fax:
Mailing address:
  • Phone: 801-244-8968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7078841-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: