MEDICARE: JED T WIDDISON CRNA

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	367500000X	Certified Registered Nurse Anesthetist	362537-4406	UT

General Provider Information

NPI Number	:	1598731598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JED T WIDDISON CRNA

Provider Business Mailing Address
First Line	:	320 RIVER PARK DR
Second Line	:	SUITE 125
City	:	PROVO
State	:	UT
Zip	:	84604-6060
Country	:	US
Telephone Number	:	801-437-4500
Fax Number	:

Provider Business Practice Location Address
First Line	:	320 RIVER PARK DR STE 125
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604-6065
Country	:	US
Telephone Number	:	801-437-4500
Fax Number	:

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

Provider Enumeration Date	:	02/28/2006
Last Update Date	:	08/27/2009

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