Basic Information
| Provider Information | |||||||||
| NPI: | 1063430890 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | BRAD | ||||||||
| MiddleName: | RODNEY | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 127 S. 500 E. | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841021971 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015876336 | ||||||||
| FaxNumber: | 8017158228 | ||||||||
| Practice Location | |||||||||
| Address1: | 2950 N CHURCH ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840406504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017717700 | ||||||||
| FaxNumber: | 8015462422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 08/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA0272 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 5166627-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.