Provider Demographics
NPI:1275502726
Name:WETJEN, NICHOLAS M (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:M
Last Name:WETJEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7147 VISTA DR STE 150
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-9313
Mailing Address - Country:US
Mailing Address - Phone:515-875-9925
Mailing Address - Fax:515-875-9923
Practice Address - Street 1:1215 PLEASANT ST STE 608
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1418
Practice Address - Country:US
Practice Address - Phone:515-241-5760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01087764A207T00000X
MN43826207T00000X
IAMD-45106207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300062435Medicaid
IN1102242609OtherANTHEM PTAN
ININ4866038OtherMEDICARE PTAN