Healthcare Provider Details

I. General information

NPI: 1134190200
Provider Name (Legal Business Name): JOHN R GILBERT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 FAIRVIEW BLVD
WYOMING MN
55092-8013
US

IV. Provider business mailing address

5200 FAIRVIEW BLVD
WYOMING MN
55092-8013
US

V. Phone/Fax

Practice location:
  • Phone: 651-464-4611
  • Fax: 651-464-7627
Mailing address:
  • Phone: 651-464-4611
  • Fax: 651-464-7627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR0838858
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: