Healthcare Provider Details

I. General information

NPI: 1164754065
Provider Name (Legal Business Name): MICHAEL D WEIS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 6TH AVE N
SAINT CLOUD MN
56303-1900
US

IV. Provider business mailing address

3701 12TH ST N SUITE 202
SAINT CLOUD MN
56303-2255
US

V. Phone/Fax

Practice location:
  • Phone: 320-258-3090
  • Fax:
Mailing address:
  • Phone: 320-258-3090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR 166559-6
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: