Healthcare Provider Details

I. General information

NPI: 1326157231
Provider Name (Legal Business Name): STEVEN D YDSTIE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 MARSH ST
MANKATO MN
56001-4752
US

IV. Provider business mailing address

10 CAMDEN CT
NORTH MANKATO MN
56003-4246
US

V. Phone/Fax

Practice location:
  • Phone: 507-345-2623
  • Fax: 507-389-4685
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR145489-1
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: