MEDICARE: MR. JOSEPH WALTER STEPHANIE 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	R 063332-5	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R 063332-5	OTHER	MN	NURSING LICENSE

General Provider Information

NPI Number	:	1235107285
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSEPH WALTER STEPHANIE CRNA

Provider Business Mailing Address
First Line	:	55837 E HIGHWAY 55
Second Line	:	BOX 121
City	:	PAYNESVILLE
State	:	MN
Zip	:	56362-9394
Country	:	US
Telephone Number	:	320-243-3908
Fax Number	:

Provider Business Practice Location Address
First Line	:	55837 E HIGHWAY 55
Second Line	:	BOX 121
City	:	PAYNESVILLE
State	:	MN
Zip	:	56362-9394
Country	:	US
Telephone Number	:	320-243-3908
Fax Number	:

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

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	07/08/2007

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