Healthcare Provider Details

I. General information

NPI: 1053512665
Provider Name (Legal Business Name): WENDY MIDGLEY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10462 S REDWOOD RD
SOUTH JORDAN UT
84095-8501
US

IV. Provider business mailing address

2678 EDGEHILL DR
BOUNTIFUL UT
84010-4330
US

V. Phone/Fax

Practice location:
  • Phone: 801-352-9500
  • Fax: 801-352-9502
Mailing address:
  • Phone: 801-808-2970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6324228-1206
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number6324228-126PA
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number6324228-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: