Healthcare Provider Details

I. General information

NPI: 1972620953
Provider Name (Legal Business Name): DEBORAH A IDLAND CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 01/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1526 NORTHWAY DR
SAINT CLOUD MN
56303-1255
US

IV. Provider business mailing address

824 15TH AVE N
SARTELL MN
56377-1999
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-8385
  • Fax:
Mailing address:
  • Phone: 320-202-2299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number042674
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: