Provider Demographics
NPI:1457803983
Name:WIEDERIN, CORY (CRNA)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:WIEDERIN
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 1:13560 TECHNOLOGY DR APT 1320
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-2264
Mailing Address - Country:US
Mailing Address - Phone:515-783-4909
Mailing Address - Fax:
Practice Address - Street 1:1455 29TH ST
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1302
Practice Address - Country:US
Practice Address - Phone:785-341-0418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-01
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI218994163W00000X
IA127888163W00000X
MN220185-2163W00000X
IAD127888367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse