Healthcare Provider Details

I. General information

NPI: 1255497004
Provider Name (Legal Business Name): BENJAMIN CLARK SICKLER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 HIGHWAY 65 S
MORA MN
55051-1899
US

IV. Provider business mailing address

35463 PALISADE DR NE
CAMBRIDGE MN
55008-8054
US

V. Phone/Fax

Practice location:
  • Phone: 320-225-3335
  • Fax: 320-225-3345
Mailing address:
  • Phone: 763-689-1008
  • Fax: 320-225-3345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number076734
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: