Healthcare Provider Details

I. General information

NPI: 1598731598
Provider Name (Legal Business Name): JED T WIDDISON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 08/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 RIVER PARK DR STE 125
PROVO UT
84604-6065
US

IV. Provider business mailing address

320 RIVER PARK DR SUITE 125
PROVO UT
84604-6060
US

V. Phone/Fax

Practice location:
  • Phone: 801-437-4500
  • Fax:
Mailing address:
  • Phone: 801-437-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number362537-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: