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NPI Code Detail

MEDICARE: MR. BRUCE WARELO SPERRY PT, PA-C

MEDICARE: MR. BRUCE WARELO SPERRY PT, PA-C
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
1363AS0400XSurgical Physician Assistant116471-1206UT

General Provider Information

NPI Number : 1760575518
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. BRUCE WARELO SPERRY PT, PA-C
Provider Business Mailing Address
First Line : 7181 S CAMPUS VIEW DR STE 200
Second Line :
City : WEST JORDAN
State : UT
Zip : 84084-4312
Country : US
Telephone Number : 801-965-3600
Fax Number :
Provider Business Practice Location Address
First Line : 4252 S HIGHLAND DR STE 200
Second Line :
City : HOLLADAY
State : UT
Zip : 84124-2690
Country : US
Telephone Number : 801-993-1800
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/02/2006
Last Update Date : 02/16/2021

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