Healthcare Provider Details

I. General information

NPI: 1851721013
Provider Name (Legal Business Name): TODD MICHAEL WIESE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2013
Last Update Date: 12/20/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 TRIUMPH BOULEVARD
LEHI UT
84043
US

IV. Provider business mailing address

2615 W COTTONWOOD DR
LEHI UT
84043-5874
US

V. Phone/Fax

Practice location:
  • Phone: 385-345-3000
  • Fax:
Mailing address:
  • Phone: 801-616-0607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number7417935-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: