=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205166493
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW JAMES HAMIEL CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2010
-----------------------------------------------------
Last Update Date | 01/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 HIGHWAY 65 S
-----------------------------------------------------
City | MORA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55051-1899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-225-3428
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 608 SPRING ST
-----------------------------------------------------
City | MENDOTA HEIGHTS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55118-1842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-245-5813
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | R1702543
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------