Provider Demographics
NPI:1568894707
Name:HAGLOCH, JOSEPH BRENT (PA-C, RDN)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:BRENT
Last Name:HAGLOCH
Suffix:
Gender:M
Credentials:PA-C, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5169 S COTTONWOOD ST STE 320
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6768
Mailing Address - Country:US
Mailing Address - Phone:801-507-2531
Mailing Address - Fax:
Practice Address - Street 1:5169 S COTTONWOOD ST STE 320
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6768
Practice Address - Country:US
Practice Address - Phone:801-507-2531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8733335-4901133V00000X
UT8733335-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered