Provider Demographics
NPI:1023039369
Name:UNDERDAHL, TODD D (CRNA)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:D
Last Name:UNDERDAHL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58122-0001
Mailing Address - Country:US
Mailing Address - Phone:701-234-6258
Mailing Address - Fax:701-234-7334
Practice Address - Street 1:737 BROADWAY
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58122-0001
Practice Address - Country:US
Practice Address - Phone:701-234-6258
Practice Address - Fax:701-234-7334
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR22985367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
N/AMedicare UPIN