Provider Demographics
NPI:1841271095
Name:GIBSON, BRANDT RYAN (DPM)
Entity type:Individual
Prefix:DR
First Name:BRANDT
Middle Name:RYAN
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:358 N 1100 E STE 1
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-3250
Mailing Address - Country:US
Mailing Address - Phone:801-756-0765
Mailing Address - Fax:081-756-1405
Practice Address - Street 1:358 N 1100 E STE 1
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-3250
Practice Address - Country:US
Practice Address - Phone:801-756-0765
Practice Address - Fax:081-756-1405
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5093909-0501213E00000X, 213EP1101X, 213ES0000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT79031OtherPEHP PIN
UT243399OtherALTIUS PIN
UT50939090500001OtherBCBS PIN
UT107028407101OtherIHC PIN
UT27-00195OtherUNITED HEALTH CARE PIN
UT882626OtherDMBA PIN
UT79031OtherPEHP PIN
UT005773801Medicare PIN
UT27-00195OtherUNITED HEALTH CARE PIN