Provider Demographics
NPI:1417428194
Name:HEDELIUS, MARK W (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:W
Last Name:HEDELIUS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3750
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3750
Mailing Address - Country:US
Mailing Address - Phone:800-748-4868
Mailing Address - Fax:770-701-6676
Practice Address - Street 1:3000 N TRIUMPH BLVD
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-4999
Practice Address - Country:US
Practice Address - Phone:385-345-3000
Practice Address - Fax:770-701-6676
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8006124-3102163W00000X
UT8006124-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT8006124-3102OtherDOPL