Provider Demographics
NPI:1336830108
Name:MOORE, BRECKEN DEWEY (FNP)
Entity Type:Individual
Prefix:
First Name:BRECKEN
Middle Name:DEWEY
Last Name:MOORE
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 W TUSCANY VIEW RD UNIT 1705
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-4826
Mailing Address - Country:US
Mailing Address - Phone:435-590-2312
Mailing Address - Fax:
Practice Address - Street 1:7410 S CREEK RD STE 100
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-6151
Practice Address - Country:US
Practice Address - Phone:801-816-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT120502688900363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner