Basic Information
Provider Information | |||||||||
NPI: | 1629795513 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NORMAN | ||||||||
FirstName: | KRISTOFFER | ||||||||
MiddleName: | BENJAMIN | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NORMAN | ||||||||
OtherFirstName: | KRIS | ||||||||
OtherMiddleName: | BENJAMIN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 14683 390TH ST | ||||||||
Address2: |   | ||||||||
City: | GOODHUE | ||||||||
State: | MN | ||||||||
PostalCode: | 550275007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6513801965 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 640 JACKSON ST | ||||||||
Address2: |   | ||||||||
City: | SAINT PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 551012595 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512543456 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/21/2022 | ||||||||
LastUpdateDate: | 10/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R153072 | MN | Y |   | Nursing Service Providers | Registered Nurse |   |
No ID Information.