Provider Demographics
NPI:1851721013
Name:WIESE, TODD MICHAEL (CRNA)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:MICHAEL
Last Name:WIESE
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 1:2615 W COTTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-5874
Mailing Address - Country:US
Mailing Address - Phone:801-616-0607
Mailing Address - Fax:
Practice Address - Street 1:3000 TRIUMPH BOULEVARD
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043
Practice Address - Country:US
Practice Address - Phone:385-345-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-25
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7417935-4405367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered