Provider Demographics
NPI:1194142620
Name:MOHMAND, WAGMA (PA-C, MPAS)
Entity type:Individual
Prefix:
First Name:WAGMA
Middle Name:
Last Name:MOHMAND
Suffix:
Gender:F
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 S 500 E STE 660
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2183
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1525 W 2100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-1401
Practice Address - Country:US
Practice Address - Phone:801-213-8841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-21
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6615369-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant