Provider Demographics
NPI:1033156849
Name:FONNESBECK, BRANT WAHLEN (DO)
Entity Type:Individual
Prefix:
First Name:BRANT
Middle Name:WAHLEN
Last Name:FONNESBECK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 W LOGAN HWY
Mailing Address - Street 2:PO BOX 328
Mailing Address - City:GARDEN CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84028
Mailing Address - Country:US
Mailing Address - Phone:435-764-7249
Mailing Address - Fax:
Practice Address - Street 1:550 E 1400 N STE K
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2450
Practice Address - Country:US
Practice Address - Phone:435-755-6061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5953772-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine