Provider Demographics
NPI:1063798403
Name:WASATCH NURSE PRACTITIONER SERVICES
Entity type:Organization
Organization Name:WASATCH NURSE PRACTITIONER SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:W
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:801-918-9793
Mailing Address - Street 1:3683 WILDROSE LN
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-4324
Mailing Address - Country:US
Mailing Address - Phone:801-918-9793
Mailing Address - Fax:
Practice Address - Street 1:3683 WILDROSE LN
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-4324
Practice Address - Country:US
Practice Address - Phone:801-918-9793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1166904405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty