Healthcare Provider Details

I. General information

NPI: 1184083826
Provider Name (Legal Business Name): DIRK BRADLEY BAHORAVITCH MSN, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1067 N 500 W
PROVO UT
84604-3305
US

IV. Provider business mailing address

264 N 1020 E
AMERICAN FORK UT
84003-2957
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-0354
  • Fax:
Mailing address:
  • Phone: 801-592-5424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number53485
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: