Healthcare Provider Details

I. General information

NPI: 1720668411
Provider Name (Legal Business Name): BRADON CLARK BURNINGHAM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2021
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 N 100 E STE 102
SAINT GEORGE UT
84770-7369
US

IV. Provider business mailing address

345 N 2450 E UNIT 210
SAINT GEORGE UT
84790-5754
US

V. Phone/Fax

Practice location:
  • Phone: 435-879-5101
  • Fax:
Mailing address:
  • Phone: 801-349-9897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12351455-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: