Provider Demographics
NPI:1114224805
Name:WASATCH PODIATRY PLLC
Entity Type:Organization
Organization Name:WASATCH PODIATRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AGRES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-430-8406
Mailing Address - Street 1:PO BOX 150383
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84415-0383
Mailing Address - Country:US
Mailing Address - Phone:801-430-8406
Mailing Address - Fax:
Practice Address - Street 1:5275 ADAMS AVE PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6748
Practice Address - Country:US
Practice Address - Phone:801-430-8406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-16
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7259622-0501213E00000X
261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty