Provider Demographics
NPI:1184083826
Name:BAHORAVITCH, DIRK BRADLEY (MSN, CRNA)
Entity type:Individual
Prefix:
First Name:DIRK
Middle Name:BRADLEY
Last Name:BAHORAVITCH
Suffix:
Gender:M
Credentials:MSN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 N 1020 E
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2957
Mailing Address - Country:US
Mailing Address - Phone:801-592-5424
Mailing Address - Fax:
Practice Address - Street 1:1067 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-374-0354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-22
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID53485367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered