Provider Demographics
NPI:1972048692
Name:CARLSEN, BRADY (CRNA)
Entity Type:Individual
Prefix:
First Name:BRADY
Middle Name:
Last Name:CARLSEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11526 S HIGH MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-5659
Mailing Address - Country:US
Mailing Address - Phone:509-217-0698
Mailing Address - Fax:
Practice Address - Street 1:3580 W 9000 S
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-8812
Practice Address - Country:US
Practice Address - Phone:509-217-0698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5149223-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered