Healthcare Provider Details

I. General information

NPI: 1043635360
Provider Name (Legal Business Name): JESSE STOKKE APRN, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2014
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 E 1ST ST
DULUTH MN
55805
US

IV. Provider business mailing address

915 E 1ST ST
DULUTH MN
55805-2107
US

V. Phone/Fax

Practice location:
  • Phone: 218-249-5352
  • Fax: 218-249-5534
Mailing address:
  • Phone: 218-249-5352
  • Fax: 218-249-5534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR187104-7
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA0748
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: