Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist |
NPI | 1205414117 |
---|---|
Provider Name | Braden Cunningham |
First Address | Salt Lake City, UT 84148-0001 |
Second Address | Salt Lake City, UT 84148-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/03/2021 |
Last Update Date | 31/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
802003707 | SELECT HEALTH (01) | UT |