=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265439376
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA STRUWE BRILEY MS, PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2005
-----------------------------------------------------
Last Update Date | 11/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1743 REDSTONE DRIVE SUITE 115 REDSTONE HEALTH CENTER
-----------------------------------------------------
City | PARK CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-658-9200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5699 FAIRVIEW DR
-----------------------------------------------------
City | PARK CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84098-6164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-201-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 98-289413-1206
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------