=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487657847
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY MERRIAM CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2005
-----------------------------------------------------
Last Update Date | 06/13/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9645 GROVE CIR N STE 250
-----------------------------------------------------
City | MAPLE GROVE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-201-8191
-----------------------------------------------------
Fax | 763-201-8192
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9645 GROVE CIR N STE 250
-----------------------------------------------------
City | MAPLE GROVE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55369-4466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-201-8191
-----------------------------------------------------
Fax | 763-201-8192
-----------------------------------------------------
=====================================================
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 | R121082-8
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------