Basic Information
| Provider Information | |||||||||
| NPI: | 1184393381 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TOLLEFSON | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | ODEAN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3701 12TH ST N STE 202 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202583090 | ||||||||
| FaxNumber: | 3202583090 | ||||||||
| Practice Location | |||||||||
| Address1: | 3701 12TH ST N STE 202 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202583090 | ||||||||
| FaxNumber: | 3202583090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2021 | ||||||||
| LastUpdateDate: | 10/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 2458031 | MN | N | Nursing Service Providers | Registered Nurse | 367500000X | 2613 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.