Provider Demographics
NPI:1912949603
Name:BROOKSBY, NOLAN R (DO)
Entity Type:Individual
Prefix:
First Name:NOLAN
Middle Name:R
Last Name:BROOKSBY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W 100 N
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-2036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:151 W 200 N
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-1907
Practice Address - Country:US
Practice Address - Phone:435-789-3342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT55611703-1204207PE0004X
UT5611703-1204207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP00187532OtherRAILROAD MEDICARE
UTD5681Medicaid
UT56117031200001OtherBC/BS
UTH81504Medicare UPIN
UT000012718Medicare ID - Type Unspecified
UT000059493Medicare PIN