Provider Demographics
NPI:1588825723
Name:WIEDERHOLT, BRENT (NP-C)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:WIEDERHOLT
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX J
Mailing Address - Street 2:
Mailing Address - City:FORT YATES
Mailing Address - State:ND
Mailing Address - Zip Code:58538-0527
Mailing Address - Country:US
Mailing Address - Phone:701-854-3831
Mailing Address - Fax:
Practice Address - Street 1:N10 NORTH RIVER ROAD
Practice Address - Street 2:
Practice Address - City:FORT YATES
Practice Address - State:ND
Practice Address - Zip Code:58538
Practice Address - Country:US
Practice Address - Phone:701-854-3831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR033677163WE0003X
SDSD-CNP CP000967363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency