Provider Demographics
NPI:1710985965
Name:BRAUNBERGER, KERRY S (AUD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:S
Last Name:BRAUNBERGER
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3955 HARRISON BLVD
Mailing Address - Street 2:SUITE U7
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-2313
Mailing Address - Country:US
Mailing Address - Phone:801-399-9955
Mailing Address - Fax:801-399-3144
Practice Address - Street 1:3955 HARRISON BLVD
Practice Address - Street 2:SUITE U7
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2313
Practice Address - Country:US
Practice Address - Phone:801-399-9955
Practice Address - Fax:801-399-3144
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4827256-4101174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP51096Medicare UPIN