Provider Demographics
NPI:1164168035
Name:BRYTERSON MEDICAL
Entity Type:Organization
Organization Name:BRYTERSON MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRINGHURST
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:801-367-9585
Mailing Address - Street 1:PO BOX 62
Mailing Address - Street 2:
Mailing Address - City:MONA
Mailing Address - State:UT
Mailing Address - Zip Code:84645-0062
Mailing Address - Country:US
Mailing Address - Phone:801-367-9585
Mailing Address - Fax:
Practice Address - Street 1:318 WEST 700 SOUTH
Practice Address - Street 2:#62
Practice Address - City:MONA
Practice Address - State:UT
Practice Address - Zip Code:84645
Practice Address - Country:US
Practice Address - Phone:801-367-9585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT4061849Medicaid