Basic Information
| Provider Information | |||||||||
| NPI: | 1255686259 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRIME | ||||||||
| FirstName: | GRAHAM | ||||||||
| MiddleName: | BRENT | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3810 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841103810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014322600 | ||||||||
| FaxNumber: | 8014322668 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 N 1100 E | ||||||||
| Address2: | |||||||||
| City: | AMERICAN FORK | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840032096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017633300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 07/17/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 5366606-4406 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.