Provider Demographics
NPI:1578574489
Name:PETERSON, BRYAN J (CRNA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:J
Last Name:PETERSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1954 FORT UNION BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5475 S 500 E
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6905
Practice Address - Country:US
Practice Address - Phone:800-880-3566
Practice Address - Fax:801-733-5872
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT96-321407-1205207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107007919103OtherIHC
UT2000026OtherUNITED HEALTHCARE
UT52186OtherHEALTHY U
UT561586OtherCIGNA
UTPR00532OtherMOLINA
UT219504OtherALTIUS
UT68295OtherPEHP
UT870458780PE1OtherEDUCATORS MUTUAL
UT581710OtherDESERET MUTUAL
UT870458780PE1OtherEDUCATORS MUTUAL