Basic Information
| Provider Information | |||||||||
| NPI: | 1245745629 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUBAKER | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 W 1060 N | ||||||||
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| City: | HURRICANE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847371913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4352186726 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1952 E FORT UNION BLVD | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841216877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019423311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2017 | ||||||||
| LastUpdateDate: | 12/07/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 9421945-2402 | UT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.