Provider Demographics
NPI:1144237561
Name:RICHARDSON, M. REUBEN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:M. REUBEN
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:REUBEN
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:5425 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-2511
Mailing Address - Country:US
Mailing Address - Phone:612-825-2986
Mailing Address - Fax:
Practice Address - Street 1:1 VETERANS DR
Practice Address - Street 2:ANESTHESIA DEPARTMENT 112A
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-2309
Practice Address - Country:US
Practice Address - Phone:612-467-4698
Practice Address - Fax:612-727-5961
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR093267-3367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered