Provider Demographics
NPI:1265941892
Name:BAGLEY, ADAM K (PA-C)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:K
Last Name:BAGLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4403 HARRISON BLVD STE 2400
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3297
Mailing Address - Country:US
Mailing Address - Phone:801-387-2750
Mailing Address - Fax:
Practice Address - Street 1:4403 HARRISON BLVD STE 2400
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3297
Practice Address - Country:US
Practice Address - Phone:801-387-2750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10518134-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant