Provider Demographics
NPI:1407467749
Name:SALVESON, TRACI JO (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:TRACI
Middle Name:JO
Last Name:SALVESON
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 1:7616 STATE HIGHWAY 55
Mailing Address - Street 2:
Mailing Address - City:KIMBALL
Mailing Address - State:MN
Mailing Address - Zip Code:55353-9607
Mailing Address - Country:US
Mailing Address - Phone:763-439-1911
Mailing Address - Fax:
Practice Address - Street 1:1406 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1900
Practice Address - Country:US
Practice Address - Phone:320-258-3090
Practice Address - Fax:320-258-3095
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2056887163W00000X
MN2519367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse