Healthcare Provider Details

I. General information

NPI: 1083957492
Provider Name (Legal Business Name): STEFFANIE WAGNER DVM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2013
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 W 7200 S
MIDVALE UT
84047-1041
US

IV. Provider business mailing address

308 W 7200 S
MIDVALE UT
84047-1041
US

V. Phone/Fax

Practice location:
  • Phone: 801-871-0600
  • Fax: 801-566-1155
Mailing address:
  • Phone: 801-871-0600
  • Fax: 801-566-1155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number7655356-2801
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: