Healthcare Provider Details

I. General information

NPI: 1437508116
Provider Name (Legal Business Name): BRIAN K. PENROSE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2016
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 N 500 E
LOGAN UT
84341-2400
US

IV. Provider business mailing address

1350 N 500 E
LOGAN UT
84341-2400
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 435-716-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07001313A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number13232441-0501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: