MEDICARE: JORDAN LEE BAGNALL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1497558985
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN LEE BAGNALL MD

Provider Business Mailing Address
First Line	:	1505 BROAD AVE APT A
Second Line	:
City	:	CHARLOTTESVILLE
State	:	VA
Zip	:	22903-3721
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	195 CENTRAL CAMPUS DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84112-0519
Country	:	US
Telephone Number	:	801-581-3811
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2025
Last Update Date	:	03/31/2025

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