Healthcare Provider Details

I. General information

NPI: 1598596025
Provider Name (Legal Business Name): NATHAN BRADLEY SMART FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5314 N 250 W STE 220
PROVO UT
84604-7746
US

IV. Provider business mailing address

1836 E MOORE CREST CT
SALT LAKE CITY UT
84121-4832
US

V. Phone/Fax

Practice location:
  • Phone: 801-225-8484
  • Fax:
Mailing address:
  • Phone: 801-580-6151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14109549-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: