Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207XX0005X | Sports Medicine Orthopaedic Surgeon | 5280409-1205 | UT |
NPI | 1073543740 |
---|---|
Provider Name | Brian W Fukushima |
First Address | Murray, UT 84107-5838 |
Second Address | Murray, UT 84107-5838 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/07/2006 |
Last Update Date | 03/01/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H96575 | (02) | UT |