MEDICARE: TIMOTHY JOHN CLUNE C.R.N.A

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-082905-8	MN

General Provider Information

NPI Number	:	1720082639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY JOHN CLUNE C.R.N.A

Provider Business Mailing Address
First Line	:	15137 SHADOW CREEK RD
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-1512
Country	:	US
Telephone Number	:	612-801-6419
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 CHICAGO AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-4518
Country	:	US
Telephone Number	:	612-813-8100
Fax Number	:

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

Provider Enumeration Date	:	06/08/2005
Last Update Date	:	07/18/2014

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