Provider Demographics
NPI:1003052218
Name:FERGUSON, MELANIE A (CRNA)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:A
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:A
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8681 EAGLE POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-8628
Mailing Address - Country:US
Mailing Address - Phone:651-251-8021
Mailing Address - Fax:651-251-8050
Practice Address - Street 1:69 EXCHANGE ST W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1004
Practice Address - Country:US
Practice Address - Phone:651-735-0501
Practice Address - Fax:651-735-1870
Is Sole Proprietor?:No
Enumeration Date:2008-12-18
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR161452-1367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered