Basic Information
| Provider Information | |||||||||
| NPI: | 1588942627 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULTJE | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HANSEN | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | R | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5045 | ||||||||
| Address2: | ATTN: P.F.S. PROVIDER ENROLLMENT | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053226428 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1325 S CLIFF AVE | ||||||||
| Address2: | ANESTHESIA DEPT | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053222754 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2011 | ||||||||
| LastUpdateDate: | 01/03/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | CR000766 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1588942627 | 05 | IA | MEDICAID | 1588942627 | 01 | BCBS MN | OTHER | 1588942627 | 01 | DAKOTACARE | OTHER | 1588942627 | 01 | WELLMARK BCBS/TRICARE | OTHER | 1588942627 | 05 | MN | MEDICAID | 575690 | 05 | SD | MEDICAID | 46022474348 | 05 | NE | MEDICAID |