Basic Information
| Provider Information | |||||||||
| NPI: | 1871973198 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TERRY | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | WESCOTT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 475 W 940 N | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577940 | ||||||||
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| Practice Location | |||||||||
| Address1: | 360 E LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | WEISER | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836722261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085494424 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2015 | ||||||||
| LastUpdateDate: | 03/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 9832809-1204 | UT | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | O-1122 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.