Provider Demographics
NPI:1235398645
Name:ERICKSON, GRANT BRYAN
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:BRYAN
Last Name:ERICKSON
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:DEPT VASCULAR SURGEY
Mailing Address - Street 2:30 NORTH 1900 EAST, ROOM 3C 344 SOM
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0001
Mailing Address - Country:US
Mailing Address - Phone:801-581-8301
Mailing Address - Fax:801-581-3433
Practice Address - Street 1:DEPT VASCULAR SURGEY
Practice Address - Street 2:30 NORTH 1900 EAST, ROOM 3C 344 SOM
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-8301
Practice Address - Fax:801-581-3433
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6916493-12052086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery