MEDICARE: LYNETTE ROTH NYGAARD 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	367500000X	Certified Registered Nurse Anesthetist	R17884	ND

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3553	OTHER	ND	BLUE CROSS OF ND
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144255787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNETTE ROTH NYGAARD CRNA

Provider Business Mailing Address
First Line	:	1301 15TH AVE W
Second Line	:
City	:	WILLISTON
State	:	ND
Zip	:	58801-3821
Country	:	US
Telephone Number	:	701-774-7400
Fax Number	:	701-774-7479

Provider Business Practice Location Address
First Line	:	1301 15TH AVE W
Second Line	:
City	:	WILLISTON
State	:	ND
Zip	:	58801-3821
Country	:	US
Telephone Number	:	701-774-7400
Fax Number	:	701-774-7479

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

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	07/08/2007

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