Healthcare Provider Details

I. General information

NPI: 1619939501
Provider Name (Legal Business Name): RUSSELL ALAN HAUGE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 EAST BLVD
ELKHART IN
46514-2483
US

IV. Provider business mailing address

4864 CROWN LN
WOODBURY MN
55129-8900
US

V. Phone/Fax

Practice location:
  • Phone: 574-524-8130
  • Fax: 574-524-8138
Mailing address:
  • Phone: 651-459-8513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number120711-6
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4677
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28195266A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA0267
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: