Healthcare Provider Details

I. General information

NPI: 1205024122
Provider Name (Legal Business Name): DAVID WESLEY BROCK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 02/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 N UNIVERSITY AVE SUITE 250
PROVO UT
84604-6683
US

IV. Provider business mailing address

100 N MARIO CAPECCHI DR SUITE 250
SALT LAKE CITY UT
84113-1103
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-9625
  • Fax: 801-374-9690
Mailing address:
  • Phone: 801-662-5582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number6725565-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: