Healthcare Provider Details

I. General information

NPI: 1417428194
Provider Name (Legal Business Name): MARK W HEDELIUS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2018
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 N TRIUMPH BLVD
LEHI UT
84043-4999
US

IV. Provider business mailing address

PO BOX 3750
SALT LAKE CITY UT
84110-3750
US

V. Phone/Fax

Practice location:
  • Phone: 385-345-3000
  • Fax: 770-701-6676
Mailing address:
  • Phone: 800-748-4868
  • Fax: 770-701-6676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number8006124-3102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number8006124-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: