Provider Demographics
NPI:1083234975
Name:BOWERBANK, LANDON RYAN (DPM)
Entity Type:Individual
Prefix:
First Name:LANDON
Middle Name:RYAN
Last Name:BOWERBANK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9980 S 300 W STE 310
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-3654
Mailing Address - Country:US
Mailing Address - Phone:801-631-7997
Mailing Address - Fax:
Practice Address - Street 1:3715 W 4100 S STE 150
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84120-5552
Practice Address - Country:US
Practice Address - Phone:801-253-6886
Practice Address - Fax:801-253-6888
Is Sole Proprietor?:No
Enumeration Date:2020-04-21
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13221936-0501213ES0131X, 213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist