Canyon Medical Group LLC

Primary specialty

Pediatrics PhysicianTaxonomy code 208000000X

License

0708814 Issued in UT

Legal business name

CANYON MEDICAL GROUP LLC

Practice address

1624 N 200 E Ste 160
Logan, UT 84341-3175

Phone

(435) 750-5599

Fax

(435) 750-0861

NPI assigned

Oct 10, 2007

Last updated

Jan 23, 2023By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Wendy Wimmer

Title

Manager

Phone

(435) 750-5599

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Treehouse Pediatrics & Family Care LLC Former legal business name

Medicare fee-for-service enrollment

Enrolled in UT

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Kacie Lofgran, FNP

  • Family Nurse Practitioner
  • Salt Lake City, UT
  • NPI 1710420617
  Medicare reassignment Care Compare group NPD
• Jeremy C Starr, DO

  • Family Medicine Physician
  • North Logan, UT
  • NPI 1699876987
  Medicare reassignment Care Compare group NPD
• Marybeth Wilson, F.N.P

  • Family Nurse Practitioner
  • Logan, UT
  • NPI 1487925012
  Medicare reassignment Care Compare group NPD
• Crystal Anne Burtis, PHYSICIAN ASSISTANT

  • Physician Assistant
  • Logan, UT
  • NPI 1477067775
  Medicare reassignment
• Madison Kalei Cutler, PA

  • Physician Assistant
  • Logan, UT
  • NPI 1336923135
  Medicare reassignment
• Robert Duncan

  • Pediatrics Physician
  • Logan, UT
  • NPI 1801530084
  NPD
• Alberto W Souza, NP

  • Psychiatric/Mental Health Nurse Practitioner
  • St George, UT
  • NPI 1972846384
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1191974400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1674432000000",
    "number": "1952599409",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1624 N 200 E STE 160",
            "city": "LOGAN",
            "state": "UT",
            "postal_code": "843413175",
            "telephone_number": "435-750-5599",
            "fax_number": "435-750-0861"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1624 N 200 E STE 160",
            "city": "LOGAN",
            "state": "UT",
            "postal_code": "843413175",
            "telephone_number": "435-750-5599",
            "fax_number": "435-750-0861"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CANYON MEDICAL GROUP LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-10-10",
        "last_updated": "2023-01-23",
        "certification_date": "2023-01-23",
        "status": "A",
        "authorized_official_last_name": "WIMMER",
        "authorized_official_first_name": "WENDY",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "435-750-5599"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "UT",
            "license": "0708814",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "528291883001",
            "state": "UT"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Treehouse Pediatrics & Family Care LLC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

• Todd Campbell
• Campus Academy (Juniper Haven)
• Conrad Cannell, LMFT
• Canyon Breeze Counseling
• Canyon Medical Group
• Ena C. Cardona-Mason, N.P.
• Care Planning Institute, Inc
• Careforward Home Care Ut LLC
• Diane Carling, OT
• Brian W Carlson, MD

• Pediatrics Physician in Logan, UT
• Providers in Logan, UT by specialty
• Pediatrics Physician in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 23, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.