Healthcare Provider Details

I. General information

NPI: 1396322699
Provider Name (Legal Business Name): GARRETT BURGON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 08/17/2024
Certification Date: 08/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3578 E PONY EXPRESS PKWY
EAGLE MOUNTAIN UT
84005-6088
US

IV. Provider business mailing address

3578 E PONY EXPRESS PKWY
EAGLE MOUNTAIN UT
84005-6088
US

V. Phone/Fax

Practice location:
  • Phone: 801-435-7980
  • Fax:
Mailing address:
  • Phone: 801-435-7980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number13791484-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: