Provider Demographics
NPI:1073516266
Name:KLICK, JOSEPH MICHAEL (CRNA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MICHAEL
Last Name:KLICK
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 1:400 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-4552
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:952-442-3620
Practice Address - Street 1:717 S STATE ST
Practice Address - Street 2:STE 100
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4470
Practice Address - Country:US
Practice Address - Phone:507-235-3939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0799010367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN27G81KLOtherBLUE CROSS MN
MN430056096OtherPALMETTO GBA RR MC
MN177742400Medicaid
MN2552OtherARAZ
MN143425200OtherUS DEPARTMENT OF LABOR
MN1103036OtherARAZ
MN27G81KLOtherBLUE CROSS MN