Healthcare Provider Details

I. General information

NPI: 1508289794
Provider Name (Legal Business Name): JOHN MICHAEL MIKKELSEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2014
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S COLUMBIA RD - ALTRU HOSPITAL
GRAND FORKS ND
58201
US

IV. Provider business mailing address

2401 DEMERS AVE
GRAND FORKS ND
58201
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-6000
  • Fax: 701-364-8078
Mailing address:
  • Phone: 701-780-1891
  • Fax: 701-364-8078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR36883
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: