Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 3095297-8016 | UT |
NPI | 1063865699 |
---|---|
Provider Name | Bridger Park |
First Address | Provo, UT 84604 |
Second Address | Provo, UT 84604 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/07/2016 |
Last Update Date | 19/07/2016 |