Healthcare Provider Details

I. General information

NPI: 1497238604
Provider Name (Legal Business Name): TODD RICHARD MOLENAAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2018
Last Update Date: 09/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

REGIONS HOSPITAL 640 JACKSON STREET MAIL STOP 13901C
ST PAUL MN
55101-2502
US

IV. Provider business mailing address

PO BOX 1309
MINNEAPOLIS MN
55440-1309
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-3456
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number120879
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2240
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: