Healthcare Provider Details

I. General information

NPI: 1417408147
Provider Name (Legal Business Name): TIMOTHY WILSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 28TH ST
MINNEAPOLIS MN
55407-3723
US

IV. Provider business mailing address

4401 PARK GLEN RD APT 306
ST LOUIS PARK MN
55416-4768
US

V. Phone/Fax

Practice location:
  • Phone: 612-863-4000
  • Fax:
Mailing address:
  • Phone: 707-315-7142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR 215550-0
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number111898
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: