Healthcare Provider Details

I. General information

NPI: 1912949603
Provider Name (Legal Business Name): NOLAN R. BROOKSBY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 04/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 W 200 N
VERNAL UT
84078-1907
US

IV. Provider business mailing address

150 W 100 N
VERNAL UT
84078-2036
US

V. Phone/Fax

Practice location:
  • Phone: 435-789-3342
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5611703-1204
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number55611703-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: