Healthcare Provider Details

I. General information

NPI: 1154083988
Provider Name (Legal Business Name): LAURA L DYSTE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURA J LILJA CRNA

II. Dates (important events)

Enumeration Date: 10/08/2021
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 HARVARD ST SE
MINNEAPOLIS MN
55455-0363
US

IV. Provider business mailing address

420 DELAWARE ST SE
MINNEAPOLIS MN
55455-0341
US

V. Phone/Fax

Practice location:
  • Phone: 612-273-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2650
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: