Provider Demographics
NPI:1710370770
Name:WATKINS, BRADY MARK (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRADY
Middle Name:MARK
Last Name:WATKINS
Suffix:
Gender:M
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 1:13825 S REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BLUFFDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84065-5222
Mailing Address - Country:US
Mailing Address - Phone:801-254-9700
Mailing Address - Fax:
Practice Address - Street 1:13825 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:BLUFFDALE
Practice Address - State:UT
Practice Address - Zip Code:84065-5222
Practice Address - Country:US
Practice Address - Phone:801-254-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-13
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9270329-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant