Healthcare Provider Details

I. General information

NPI: 1972048692
Provider Name (Legal Business Name): BRADY CARLSEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2017
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3580 W 9000 S
WEST JORDAN UT
84088-8812
US

IV. Provider business mailing address

11526 S HIGH MOUNTAIN DR
SANDY UT
84092-5659
US

V. Phone/Fax

Practice location:
  • Phone: 509-217-0698
  • Fax:
Mailing address:
  • Phone: 509-217-0698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number5149223-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: