Provider Demographics
NPI:1316938673
Name:BODEN, BRIAN T (PAC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:T
Last Name:BODEN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-714-5000
Mailing Address - Fax:
Practice Address - Street 1:1975 N STATE ST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-2028
Practice Address - Country:US
Practice Address - Phone:801-714-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1391363AM0700X
UT7060654-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200052790AMedicaid
UT000065579Medicare PIN
OK248534408Medicare ID - Type Unspecified
OK200052790AMedicaid
Q36175Medicare UPIN
OK248534409Medicare ID - Type Unspecified