Provider Demographics
NPI:1922425800
Name:EDWARDS, GARY ROBERT
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ROBERT
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 N TRIUMPH BLVD STE 330
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-4999
Mailing Address - Country:US
Mailing Address - Phone:385-345-3560
Mailing Address - Fax:
Practice Address - Street 1:3000 N TRIUMPH BLVD STE 330
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-4999
Practice Address - Country:US
Practice Address - Phone:385-345-3560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5583016-1205207X00000X
390200000X
UT5583016-1205207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1922425800Medicaid