Healthcare Provider Details

I. General information

NPI: 1205414117
Provider Name (Legal Business Name): BRADEN CUNNINGHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3903 MEDICAL DR STE 200
OGDEN UT
84403-2318
US

IV. Provider business mailing address

3903 MEDICAL DR STE 200
OGDEN UT
84403-2318
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-5300
  • Fax: 801-387-5333
Mailing address:
  • Phone: 801-387-5300
  • Fax: 801-387-5333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code246RH0600X
TaxonomyHistology Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: