Individual
BRANT WAHLEN FONNESBECK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
550 E 1400 N STE K, LOGAN, UT 84341-2450
(435) 755-6061
Mailing address
325 W LOGAN HWY, PO BOX 328, GARDEN CITY, UT 84028
(435) 764-7249
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
5953772-1204
UT
Other
Enumeration date
06/01/2006
Last updated
02/26/2008
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