Provider Demographics
NPI:1598097537
Name:VANWAGONER, NICK (LMT)
Entity Type:Individual
Prefix:
First Name:NICK
Middle Name:
Last Name:VANWAGONER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:643 W 700 N STE C
Mailing Address - Street 2:
Mailing Address - City:LINDON
Mailing Address - State:UT
Mailing Address - Zip Code:84042-1366
Mailing Address - Country:US
Mailing Address - Phone:801-796-0322
Mailing Address - Fax:801-796-1038
Practice Address - Street 1:643 W 700 N STE C
Practice Address - Street 2:
Practice Address - City:LINDON
Practice Address - State:UT
Practice Address - Zip Code:84042-1366
Practice Address - Country:US
Practice Address - Phone:801-796-0322
Practice Address - Fax:801-796-1038
Is Sole Proprietor?:No
Enumeration Date:2010-02-01
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT73978114701174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist