1194769737 NPI number — MR. KENNETH GENE WETJEN CRNA

Table of content: MR. KENNETH GENE WETJEN CRNA (NPI 1194769737)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194769737 NPI number — MR. KENNETH GENE WETJEN CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WETJEN
Provider First Name:
KENNETH
Provider Middle Name:
GENE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WETJEN
Provider Other First Name:
KENNETH
Provider Other Middle Name:
GENE
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1194769737
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18 PHOENIX PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IOWA CITY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52246-8665
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-339-0097
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 HIGHWAY 6 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IOWA CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52246-2292
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-338-0581
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/15/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 374T00000X , with the licence number:  R 094024-1 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: R 094024-1 . This is a "NURSING LISCENSE" identifier . This identifiers is of the category "OTHER".