Healthcare Provider Details

I. General information

NPI: 1871121798
Provider Name (Legal Business Name): JUSTIN JOHN WAGNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3723 W 12600 S STE 270
RIVERTON UT
84065-7296
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-285-4600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number14276836-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: