1063430890 NPI number — BRAD RODNEY LARSEN P.A.

Table of content: BRAD RODNEY LARSEN P.A. (NPI 1063430890)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063430890 NPI number — BRAD RODNEY LARSEN P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSEN
Provider First Name:
BRAD
Provider Middle Name:
RODNEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063430890
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
127 S. 500 E.
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84102-1971
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-587-6336
Provider Business Mailing Address Fax Number:
801-715-8228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2950 N CHURCH ST
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
LAYTON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84040-6504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-771-7700
Provider Business Practice Location Address Fax Number:
801-546-2422
Provider Enumeration Date:
07/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA0272 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 5166627-1206 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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