Provider Demographics
NPI:1194769737
Name:WETJEN, KENNETH GENE (CRNA)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:GENE
Last Name:WETJEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:MR
Other - First Name:KENNETH
Other - Middle Name:GENE
Other - Last Name:WETJEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:18 PHOENIX PL
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52246-8665
Mailing Address - Country:US
Mailing Address - Phone:319-339-0097
Mailing Address - Fax:
Practice Address - Street 1:601 HIGHWAY 6 W
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52246-2292
Practice Address - Country:US
Practice Address - Phone:319-338-0581
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 094024-1374T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374T00000XNursing Service Related ProvidersReligious Nonmedical Nursing Personnel
Provider Identifiers
StateIdentifier IDID TypeIssuer
R 094024-1OtherNURSING LISCENSE