Healthcare Provider Details

I. General information

NPI: 1740953488
Provider Name (Legal Business Name): BRYAN WIEDERHOLT DNAP, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2021
Last Update Date: 03/03/2023
Certification Date: 03/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 W. CHARLESTON BLVD.
LAS VEGAS NV
89102
US

IV. Provider business mailing address

1800 W. CHARLESTON BLVD.
LAS VEGAS NV
89102
US

V. Phone/Fax

Practice location:
  • Phone: 702-383-2000
  • Fax: 702-383-3620
Mailing address:
  • Phone: 702-383-2000
  • Fax: 702-383-3620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number845062
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: