Provider Demographics
NPI:1548204290
Name:BRYAN, NATHANIEL A (MD)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:A
Last Name:BRYAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-501-5500
Mailing Address - Fax:801-501-5800
Practice Address - Street 1:9450 S 1300 E
Practice Address - Street 2:SUITE 120
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-5555
Practice Address - Country:US
Practice Address - Phone:801-501-5500
Practice Address - Fax:801-501-6155
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2016-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4978859-1205207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942854057100Medicaid
UT000063095Medicare PIN
UTI36102Medicare UPIN