Healthcare Provider Details

I. General information

NPI: 1629342548
Provider Name (Legal Business Name): BRADEN WILSON WOLTHUIS ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2012
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 HARRISON BOULEVARD
OGDEN UT
84403
US

IV. Provider business mailing address

4401 HARRISON BOULEVARD MCKAY-DEE HOSPITAL ACUTE PAIN SERVICE
OGDEN UT
84403
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-2371
  • Fax:
Mailing address:
  • Phone: 801-387-2371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number8055787-3102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number8055787-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: