Basic Information
| Provider Information | |||||||||
| NPI: | 1265861892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURTON | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 300 W | ||||||||
| Address2: | STE 316 | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577530 | ||||||||
| FaxNumber: | 8013577566 | ||||||||
| Practice Location | |||||||||
| Address1: | 5848 S FASHION BLVD STE 110 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841076121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013144188 | ||||||||
| FaxNumber: | 8013144015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2013 | ||||||||
| LastUpdateDate: | 01/04/2017 | ||||||||
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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 | 363AS0400X | 8813502-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.