MEDICARE: BRANT WAHLEN FONNESBECK DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	5953772-1204	UT

General Provider Information

NPI Number	:	1033156849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANT WAHLEN FONNESBECK DO

Provider Business Mailing Address
First Line	:	325 W LOGAN HWY
Second Line	:	PO BOX 328
City	:	GARDEN CITY
State	:	UT
Zip	:	84028
Country	:	US
Telephone Number	:	435-764-7249
Fax Number	:

Provider Business Practice Location Address
First Line	:	550 E 1400 N STE K
Second Line	:
City	:	LOGAN
State	:	UT
Zip	:	84341-2450
Country	:	US
Telephone Number	:	435-755-6061
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	02/26/2008

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