Provider Demographics
NPI:1053545434
Name:WENNERGREN, JOHN EMIL (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EMIL
Last Name:WENNERGREN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3550 N UNIVERSITY AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6695
Mailing Address - Country:US
Mailing Address - Phone:801-374-9625
Mailing Address - Fax:
Practice Address - Street 1:3550 N UNIVERSITY AVE STE 250
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6695
Practice Address - Country:US
Practice Address - Phone:801-374-9625
Practice Address - Fax:801-374-9625
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY47353208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery