Healthcare Provider Details

I. General information

NPI: 1326147034
Provider Name (Legal Business Name): BRYAN BERNELL HOFHEINS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 500 W STE 102
PROVO UT
84604-3305
US

IV. Provider business mailing address

703 STRAWBERRY RD
SALEM UT
84653-5695
US

V. Phone/Fax

Practice location:
  • Phone: 385-203-1107
  • Fax: 801-429-0629
Mailing address:
  • Phone: 435-632-2845
  • Fax: 801-429-0629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number378238-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number378238-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: