Basic Information
| Provider Information | |||||||||
| NPI: | 1427664721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHORT | ||||||||
| FirstName: | CASI | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 629 EASTGATE PKWY | ||||||||
| Address2: | |||||||||
| City: | MAHTOMEDI | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551151737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3028241048 | ||||||||
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| Practice Location | |||||||||
| Address1: | 640 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551012502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512546512 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2020 | ||||||||
| LastUpdateDate: | 01/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 2364728 | MN | N | Nursing Service Providers | Registered Nurse | 367500000X | 2543 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.