Provider Demographics
NPI:1215402631
Name:BRANNON, AUSTIN EDGAR
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:EDGAR
Last Name:BRANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2580 S 300 E
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-3241
Mailing Address - Country:US
Mailing Address - Phone:801-243-1041
Mailing Address - Fax:
Practice Address - Street 1:2580 S 300 E
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-3241
Practice Address - Country:US
Practice Address - Phone:801-243-1041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11835547-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant