Healthcare Provider Details

I. General information

NPI: 1164126637
Provider Name (Legal Business Name): DUSTIN P HECK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1526 NORTHWAY DR
SAINT CLOUD MN
56303-1255
US

IV. Provider business mailing address

10155 45TH AVE NE
SAUK RAPIDS MN
56379-2003
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-8385
  • Fax:
Mailing address:
  • Phone: 320-287-0811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2018142
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2834
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: