Provider Demographics
NPI:1982696043
Name:DEWILDE, JASON T (CRNA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:T
Last Name:DEWILDE
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 1:5901 WESTOWN PKWY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-8218
Mailing Address - Country:US
Mailing Address - Phone:515-221-9222
Mailing Address - Fax:515-221-0575
Practice Address - Street 1:5901 WESTOWN PKWY
Practice Address - Street 2:SUITE 210
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8218
Practice Address - Country:US
Practice Address - Phone:515-221-9222
Practice Address - Fax:515-221-0575
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO53141163W00000X
IAD-097433367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA50171OtherGROUP MEDICARE NUMBER
IA0285411Medicaid
IA50171OtherWELLMARK
IA50171OtherWELLMARK