Provider Demographics
NPI:1689283269
Name:WAGNER, ANNA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 S LEE MAUR ST
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-4506
Mailing Address - Country:US
Mailing Address - Phone:440-258-1580
Mailing Address - Fax:
Practice Address - Street 1:3900 S LEE MAUR ST
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-4506
Practice Address - Country:US
Practice Address - Phone:440-258-1580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT10756382-3102OtherUTAH DOPL