Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081P2900X | Pain Medicine | 328393-1204 | UT |
NPI | 1154312197 |
---|---|
Provider Name | Dr. Bradley Dryden Root |
First Address | Provo, UT 84604-3305 |
Second Address | St George, UT 84790-5844 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/10/2005 |
Last Update Date | 14/06/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E86263 | (02) |