Healthcare Provider Details

I. General information

NPI: 1750301529
Provider Name (Legal Business Name): BRETT WALLACE SHARP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 03/07/2023
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1277 E 100 S
LOGAN UT
84321-4974
US

IV. Provider business mailing address

1277 E 100 S
LOGAN UT
84321-4974
US

V. Phone/Fax

Practice location:
  • Phone: 757-995-5118
  • Fax:
Mailing address:
  • Phone: 757-995-5118
  • Fax: 571-423-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number182472-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number0101-240151
License Number StateVA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier010297222
Identifier TypeMEDICAID
Identifier StateVA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: