Healthcare Provider Details

I. General information

NPI: 1780054809
Provider Name (Legal Business Name): KYLE HEFFNER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2015
Last Update Date: 10/01/2015
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

2828 CHICAGO AVE SUITE 300
MINNEAPOLIS MN
55407-1544
US

V. Phone/Fax

Practice location:
  • Phone: 612-871-7639
  • Fax:
Mailing address:
  • Phone: 612-871-7639
  • Fax: 612-872-0302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA 1811
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: