Provider Demographics
NPI:1629342548
Name:WOLTHUIS, BRADEN WILSON (ACNP)
Entity Type:Individual
Prefix:MR
First Name:BRADEN
Middle Name:WILSON
Last Name:WOLTHUIS
Suffix:
Gender:M
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 HARRISON BOULEVARD
Mailing Address - Street 2:MCKAY-DEE HOSPITAL ACUTE PAIN SERVICE
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403
Mailing Address - Country:US
Mailing Address - Phone:801-387-2371
Mailing Address - Fax:
Practice Address - Street 1:4401 HARRISON BOULEVARD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403
Practice Address - Country:US
Practice Address - Phone:801-387-2371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-24
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8055787-3102163W00000X
UT8055787-4405363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse