Basic Information
| Provider Information | |||||||||
| NPI: | 1023680519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GERUN | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNA | ||||||||
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| OtherLastName: | GERUN | ||||||||
| OtherFirstName: | BEN | ||||||||
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| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1050 W ALBION MEADOW WAY | ||||||||
| Address2: | |||||||||
| City: | BLUFFDALE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840652113 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 N TRIUMPH BLVD | ||||||||
| Address2: | |||||||||
| City: | LEHI | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840434999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3853453000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2021 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | C-APN.0004101-C-CRNA | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 8281608-4406 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.