Healthcare Provider Details

I. General information

NPI: 1912194366
Provider Name (Legal Business Name): MICHAEL JACOB WAGNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 05/16/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N MEDICAL DR
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

30 N. MARIO CAPECCHI DR. HELIX BUILDING 5050
SALT LAKE CITY UT
84112
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax:
Mailing address:
  • Phone: 801-581-6393
  • Fax: 801-581-4367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA92317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: