Healthcare Provider Details

I. General information

NPI: 1770323511
Provider Name (Legal Business Name): KYLE WONG CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2024
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S BRUCE ST
MARSHALL MN
56258-1934
US

IV. Provider business mailing address

11500 WAYZATA BLVD # 1074
MINNETONKA MN
55305-2007
US

V. Phone/Fax

Practice location:
  • Phone: 507-532-9661
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2987
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: