Healthcare Provider Details

I. General information

NPI: 1811177652
Provider Name (Legal Business Name): JORDAN LEE WALLIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 S MALL DR STE B1
ST GEORGE UT
84790-4945
US

IV. Provider business mailing address

446 S MALL DR STE B1
ST GEORGE UT
84790-4945
US

V. Phone/Fax

Practice location:
  • Phone: 435-627-8150
  • Fax: 435-580-4028
Mailing address:
  • Phone: 435-627-8150
  • Fax: 435-580-4028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number11043029-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: