Healthcare Provider Details

I. General information

NPI: 1114914736
Provider Name (Legal Business Name): BRIAN C PLATT P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 N UNIVERSITY PKWY SUITE 1A
PROVO UT
84604-1509
US

IV. Provider business mailing address

2230 N UNIVERSITY PKWY SUITE 1A
PROVO UT
84604-1509
US

V. Phone/Fax

Practice location:
  • Phone: 801-377-3413
  • Fax: 801-655-1890
Mailing address:
  • Phone: 801-377-3413
  • Fax: 801-655-1890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3302821206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: