Healthcare Provider Details

I. General information

NPI: 1316938673
Provider Name (Legal Business Name): BRIAN T BODEN PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 07/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 N STATE ST
OREM UT
84057-2028
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-714-5000
  • Fax:
Mailing address:
  • Phone: 801-714-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7060654-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1391
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: