Healthcare Provider Details

I. General information

NPI: 1205905742
Provider Name (Legal Business Name): JASON D BROTHERSON A,P.R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 W 1560 S
PROVO UT
84601-5559
US

IV. Provider business mailing address

1009 W 1560 S
PROVO UT
84601-5559
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-9100
  • Fax:
Mailing address:
  • Phone: 801-360-4630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License Number308861-4405
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number308861-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: