Provider Demographics
NPI:1578711057
Name:STODDARD, BREONY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:BREONY
Middle Name:
Last Name:STODDARD
Suffix:
Gender:F
Credentials:PA-C
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 198560
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:74 E KIMBALLS LN STE 260
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5009
Practice Address - Country:US
Practice Address - Phone:801-545-8480
Practice Address - Fax:801-253-1602
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT70914401206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical