Provider Demographics
NPI:1205905742
Name:BROTHERSON, JASON D (A,PRN)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:D
Last Name:BROTHERSON
Suffix:
Gender:M
Credentials:A,PRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 W 1560 S
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-5559
Mailing Address - Country:US
Mailing Address - Phone:801-360-4630
Mailing Address - Fax:
Practice Address - Street 1:1009 W 1560 S
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-5559
Practice Address - Country:US
Practice Address - Phone:801-374-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT308861-4405364SM0705X
UT308861-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005599002Medicare PIN