Healthcare Provider Details

I. General information

NPI: 1881010023
Provider Name (Legal Business Name): ADAM WAHLSTROM D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2014
Last Update Date: 03/07/2023
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 E 100 S
ST GEORGE UT
84790-3001
US

IV. Provider business mailing address

1240 E 100 S
ST GEORGE UT
84790-3001
US

V. Phone/Fax

Practice location:
  • Phone: 801-448-8619
  • Fax:
Mailing address:
  • Phone: 801-628-8232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number10389523-1204
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: