Healthcare Provider Details

I. General information

NPI: 1043157308
Provider Name (Legal Business Name): WADE LEE WAHLQUIST RN, BSN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

377 E RIVERSIDE DR STE B
ST GEORGE UT
84790-4749
US

IV. Provider business mailing address

1787 N 2500 W
ST GEORGE UT
84770-4737
US

V. Phone/Fax

Practice location:
  • Phone: 435-862-8273
  • Fax:
Mailing address:
  • Phone: 435-862-8273
  • Fax: 435-275-4256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number7741340-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: