Healthcare Provider Details

I. General information

NPI: 1053545434
Provider Name (Legal Business Name): JOHN EMIL WENNERGREN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2009
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 N TRIUMPH BLVD STE 250
LEHI UT
84043-7187
US

IV. Provider business mailing address

3550 N UNIVERSITY AVE STE 250
PROVO UT
84604-6695
US

V. Phone/Fax

Practice location:
  • Phone: 801-852-9480
  • Fax: 801-852-9489
Mailing address:
  • Phone: 801-374-9625
  • Fax: 801-374-9690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number9362974-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: