1063565802 NPI number — BRUCE I ERRETT CRNA

Table of content: BRUCE I ERRETT CRNA (NPI 1063565802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063565802 NPI number — BRUCE I ERRETT CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERRETT
Provider First Name:
BRUCE
Provider Middle Name:
I
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063565802
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5010
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINOT
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58702-5010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-418-8000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2305 37TH AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINOT
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58701-7669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-857-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/18/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  R27402 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 1466 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: R27402 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 13019 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 798S0ER . This is a "MN BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP46105 . This is a "HEALTHPARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2002299 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 24276 . This is a "ND BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1034321 . This is a "PREFERREDONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 312110100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".