Healthcare Provider Details

I. General information

NPI: 1225347792
Provider Name (Legal Business Name): KEITH ALLEN NELSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2010
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 ANNE ST NW
BEMIDJI MN
56601-5103
US

IV. Provider business mailing address

13911 RIDGEDALE DR SUITE 350
MINNETONKA MN
55305-1771
US

V. Phone/Fax

Practice location:
  • Phone: 218-751-5430
  • Fax:
Mailing address:
  • Phone: 952-932-0998
  • Fax: 952-932-7122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR198073-4
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: