Provider Demographics
NPI:1811177652
Name:WALLIN, JORDAN LEE (MD)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:LEE
Last Name:WALLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:446 S MALL DR STE B1
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4945
Mailing Address - Country:US
Mailing Address - Phone:435-627-8150
Mailing Address - Fax:435-580-4028
Practice Address - Street 1:446 S MALL DR STE B1
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4945
Practice Address - Country:US
Practice Address - Phone:435-627-8150
Practice Address - Fax:435-580-4028
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-09
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT11043029-1205207YX0905X
NC2008-01743207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery