Healthcare Provider Details

I. General information

NPI: 1750380176
Provider Name (Legal Business Name): ALTON HARVEY WAGNON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2890 E COTTONWOOD PKWY
SALT LAKE CITY UT
84121-7035
US

IV. Provider business mailing address

5309 MOHAWK CIR
OGDEN UT
84403-4602
US

V. Phone/Fax

Practice location:
  • Phone: 801-333-5357
  • Fax:
Mailing address:
  • Phone: 801-393-4266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number84-171442-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: