Provider Demographics
NPI:1275508111
Name:SWENSON, MARK DAVID (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:SWENSON
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 1:500 W GRANT ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55041-1143
Mailing Address - Country:US
Mailing Address - Phone:651-345-3321
Mailing Address - Fax:
Practice Address - Street 1:500 W GRANT ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MN
Practice Address - Zip Code:55041-1143
Practice Address - Country:US
Practice Address - Phone:651-345-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1344626367500000X
MN54863367500000X
MN337367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN168432900Medicaid