Provider Demographics
NPI:1134112485
Name:KLUCK, MARCIA ANN (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:ANN
Last Name:KLUCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 RIVERSIDE LN NE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-3455
Mailing Address - Country:US
Mailing Address - Phone:507-421-7293
Mailing Address - Fax:507-289-0384
Practice Address - Street 1:2650 RIVERSIDE LN NE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906
Practice Address - Country:US
Practice Address - Phone:507-421-7293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 093453-2163WG0000X
MN046716367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN71-0914963OtherEMPLOYER ID NUMBER
WI211050053Medicare Oscar/Certification
WI211050093Medicare Oscar/Certification
WIP00734395Medicare Oscar/Certification