Provider Demographics
NPI:1881010023
Name:WAHLSTROM, ADAM (DO)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:
Last Name:WAHLSTROM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 E 100 S
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-3001
Mailing Address - Country:US
Mailing Address - Phone:801-628-8232
Mailing Address - Fax:
Practice Address - Street 1:1240 E 100 S
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-3001
Practice Address - Country:US
Practice Address - Phone:801-448-8619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10389523-12042080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTFW5423823OtherDEA