Healthcare Provider Details

I. General information

NPI: 1922425800
Provider Name (Legal Business Name): GARY ROBERT EDWARDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2014
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 N TRIUMPH BLVD STE 330
LEHI UT
84043-4999
US

IV. Provider business mailing address

3000 N TRIUMPH BLVD STE 330
LEHI UT
84043-7188
US

V. Phone/Fax

Practice location:
  • Phone: 385-345-3560
  • Fax:
Mailing address:
  • Phone: 385-345-3560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number5583016-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: