MEDICARE: DANIEL DEVELDE 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	RN00082710	WA
2	367500000X	Certified Registered Nurse Anesthetist	AP30005186	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DE3509	OTHER	WA	BLUE CROSS OF WA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851353288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL DEVELDE CRNA

Provider Business Mailing Address
First Line	:	400 E 10TH ST
Second Line	:
City	:	WACONIA
State	:	MN
Zip	:	55387-4552
Country	:	US
Telephone Number	:	952-442-9770
Fax Number	:	952-442-3630

Provider Business Practice Location Address
First Line	:	901 MT VIEW DR
Second Line	:
City	:	SHELTON
State	:	WA
Zip	:	98584-4401
Country	:	US
Telephone Number	:	360-426-1611
Fax Number	:

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

Provider Enumeration Date	:	04/03/2006
Last Update Date	:	12/16/2011

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