Provider Demographics
NPI:1831641042
Name:MCDONALD, BRENT (RN)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 S 500 E
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-4406
Mailing Address - Country:US
Mailing Address - Phone:435-828-1975
Mailing Address - Fax:
Practice Address - Street 1:6822 E 1000 S
Practice Address - Street 2:
Practice Address - City:FT DUCHESNE
Practice Address - State:UT
Practice Address - Zip Code:84026
Practice Address - Country:US
Practice Address - Phone:435-725-6841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT327853-3102163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care