Healthcare Provider Details

I. General information

NPI: 1467428433
Provider Name (Legal Business Name): TODD W. WALTER APRN, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17189 CO 27 BLVD
PINE ISLAND MN
55963
US

IV. Provider business mailing address

17189 CO 27 BLVD
PINE ISLAND MN
55963
US

V. Phone/Fax

Practice location:
  • Phone: 507-356-8323
  • Fax:
Mailing address:
  • Phone: 507-261-3391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR1141722
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number58
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: