Provider Demographics
NPI:1003988205
Name:BRUDERER, SCOTT (PA)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:BRUDERER
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10433 S REDWOOD RD STE 2
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8502
Mailing Address - Country:US
Mailing Address - Phone:801-260-1919
Mailing Address - Fax:801-260-1441
Practice Address - Street 1:1126 E 12300 S
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9095
Practice Address - Country:US
Practice Address - Phone:801-545-0500
Practice Address - Fax:801-545-0626
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT282815-1206363A00000X
UT2828151206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005777103Medicare PIN
UTP46824Medicare UPIN