Healthcare Provider Details

I. General information

NPI: 1861053050
Provider Name (Legal Business Name): WILLIAM WAGNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 W 200 N STE 200
ST GEORGE UT
84770-7386
US

IV. Provider business mailing address

161 W 200 N STE 200
ST GEORGE UT
84770-7386
US

V. Phone/Fax

Practice location:
  • Phone: 435-986-2020
  • Fax: 435-652-1516
Mailing address:
  • Phone: 435-986-2020
  • Fax: 435-652-1516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number8641
License Number StateNE
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35.147743
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number13858841-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: