Provider Demographics
NPI:1104849363
Name:MUTSCHELKNAUS, DAVID L (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:MUTSCHELKNAUS
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 1:48350 265TH ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:SD
Mailing Address - Zip Code:57005-7206
Mailing Address - Country:US
Mailing Address - Phone:605-582-2374
Mailing Address - Fax:
Practice Address - Street 1:1100 E 26TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-4023
Practice Address - Country:US
Practice Address - Phone:605-338-7098
Practice Address - Fax:605-335-3505
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCR000171367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4996317OtherBLUE CROSS SD
IA1551382Medicaid
MN320S0MUOtherBLUE CROSS MN
SD5752604Medicaid
P00004664Medicare PIN
IA1551382Medicaid