Provider Demographics
NPI:1992759583
Name:EKBERG, BRIAN ARTHUR (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:ARTHUR
Last Name:EKBERG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 MEDICAL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-8925
Mailing Address - Country:US
Mailing Address - Phone:801-292-1422
Mailing Address - Fax:801-296-0436
Practice Address - Street 1:520 MEDICAL DR STE 300
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-8925
Practice Address - Country:US
Practice Address - Phone:801-292-1422
Practice Address - Fax:801-296-0436
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10504077-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1992759583Medicaid
NV102530Medicare PIN
NVFO359ZMedicare PIN
NV100509623Medicaid