Healthcare Provider Details

I. General information

NPI: 1811960123
Provider Name (Legal Business Name): BRANDON D PARK APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 HARRISON BLVD
OGDEN UT
84403-4303
US

IV. Provider business mailing address

PO BOX 5546
DENVER CO
80217-5546
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-3300
  • Fax: 801-475-3301
Mailing address:
  • Phone: 801-475-3500
  • Fax: 801-475-3414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3749704405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: