Provider Demographics
NPI:1558345397
Name:BAGLEY, JARROD (FNP)
Entity Type:Individual
Prefix:
First Name:JARROD
Middle Name:
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12433 FORT ST
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9363
Mailing Address - Country:US
Mailing Address - Phone:801-576-1086
Mailing Address - Fax:801-576-9796
Practice Address - Street 1:12433 FORT ST
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9363
Practice Address - Country:US
Practice Address - Phone:801-576-1086
Practice Address - Fax:801-576-9796
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2673844405207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP14799Medicare UPIN