Healthcare Provider Details

I. General information

NPI: 1679672661
Provider Name (Legal Business Name): KAREN J GRUBER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1519 BROKEN OAK COURT
LINO LAKES MN
55038-9603
US

IV. Provider business mailing address

1519 BROKEN OAK CT
LINO LAKES MN
55038-9603
US

V. Phone/Fax

Practice location:
  • Phone: 651-402-9328
  • Fax:
Mailing address:
  • Phone: 651-402-9328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR0867434
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: