Basic Information
| Provider Information | |||||||||
| NPI: | 1124432992 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLLINGSHEAD | ||||||||
| FirstName: | BRYSON | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013548225 | ||||||||
| FaxNumber: | 8014180941 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | KANAB | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847413260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356444100 | ||||||||
| FaxNumber: | 4356443366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2014 | ||||||||
| LastUpdateDate: | 04/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 10138818-1204 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 9408360 | KS | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.