Provider Demographics
NPI:1598731598
Name:WIDDISON, JED T (CRNA)
Entity Type:Individual
Prefix:
First Name:JED
Middle Name:T
Last Name:WIDDISON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 RIVER PARK DR
Mailing Address - Street 2:SUITE 125
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6060
Mailing Address - Country:US
Mailing Address - Phone:801-437-4500
Mailing Address - Fax:
Practice Address - Street 1:320 RIVER PARK DR STE 125
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6065
Practice Address - Country:US
Practice Address - Phone:801-437-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT362537-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered