Provider Demographics
NPI:1578711057
Name:STODDARD, BREONY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:BREONY
Middle Name:
Last Name:STODDARD
Suffix:
Gender:
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 1:74 E KIMBALLS LN STE 260
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-5009
Practice Address - Country:US
Practice Address - Phone:801-895-3146
Practice Address - Fax:801-850-6611
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT70914401206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical