Provider Demographics
NPI:1346549912
Name:VAN WAGONER, ZACHARY D (MD)
Entity Type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:D
Last Name:VAN WAGONER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3550 N UNIVERSITY AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6685
Mailing Address - Country:US
Mailing Address - Phone:801-374-9625
Mailing Address - Fax:801-374-9690
Practice Address - Street 1:1000 E 15 S
Practice Address - Street 2:STE 350
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-3246
Practice Address - Country:US
Practice Address - Phone:801-465-5602
Practice Address - Fax:801-465-4480
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-22
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT9651138-1205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery