Basic Information
| Provider Information | |||||||||
| NPI: | 1528095395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRAWFORD | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MICKELSON | ||||||||
| OtherFirstName: | BRENDA | ||||||||
| OtherMiddleName: | KRISTINE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 430 | ||||||||
| Address2: | |||||||||
| City: | SPANISH FORK | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846600430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668987136 | ||||||||
| FaxNumber: | 6169759827 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 NORTH 1100 EAST | ||||||||
| Address2: | |||||||||
| City: | AMERICAN FORK | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017146570 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 05/05/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 6132263 | UT | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
ID Information
| ID | Type | State | Issuer | Description | 00A767610 | 05 | CA | MEDICAID | D7012 | 05 | UT | MEDICAID | 107046937101 | 01 | UT | SELECT HEALTH | OTHER | 870636000BCR | 01 | UT | EDUCATORS MUTUAL | OTHER | 61322631200001 | 01 | UT | BCBS | OTHER | 987965 | 01 | UT | DESERET MUTUAL | OTHER |