MEDICARE: MRS. MARCIA ANN KLUCK CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WG0000X	General Practice Registered Nurse	R 093453-2	MN
2	367500000X	Certified Registered Nurse Anesthetist	046716	MN

General Provider Information

NPI Number	:	1134112485
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARCIA ANN KLUCK CRNA

Provider Business Mailing Address
First Line	:	2650 RIVERSIDE LN NE
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55906-3455
Country	:	US
Telephone Number	:	507-421-7293
Fax Number	:	507-289-0384

Provider Business Practice Location Address
First Line	:	2650 RIVERSIDE LN NE
Second Line	:
City	:	ROCHESTER
State	:	MN
Zip	:	55906
Country	:	US
Telephone Number	:	507-421-7293
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	09/08/2009

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