Provider Demographics
NPI:1952451718
Name:WAGEMAN, RANDALL NED (DC)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:NED
Last Name:WAGEMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 S RIVER RD
Mailing Address - Street 2:E 103
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-5507
Mailing Address - Country:US
Mailing Address - Phone:435-628-3500
Mailing Address - Fax:
Practice Address - Street 1:720 S RIVER RD
Practice Address - Street 2:E 103
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-5507
Practice Address - Country:US
Practice Address - Phone:435-628-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT170227-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor