Provider Demographics
NPI:1306029715
Name:MOUNTAIN WEST FOOT & ANKLE INSTITUTE, PLLC
Entity type:Organization
Organization Name:MOUNTAIN WEST FOOT & ANKLE INSTITUTE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDT
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-756-0765
Mailing Address - Street 1:358 N 1100 E STE 1
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-3250
Mailing Address - Country:US
Mailing Address - Phone:801-756-0765
Mailing Address - Fax:801-756-1405
Practice Address - Street 1:358 N 1100 E STE 1
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-3250
Practice Address - Country:US
Practice Address - Phone:801-756-0765
Practice Address - Fax:801-756-1405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5093909-0501213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5195010001Medicare NSC