Provider Demographics
NPI:1407885023
Name:LUNDBERG, BECCA EBBA (CRNA)
Entity Type:Individual
Prefix:
First Name:BECCA
Middle Name:EBBA
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANN
Other - Last Name:LUNDBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:701 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1623
Mailing Address - Country:US
Mailing Address - Phone:612-873-6005
Mailing Address - Fax:612-630-8242
Practice Address - Street 1:701 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1623
Practice Address - Country:US
Practice Address - Phone:612-873-3152
Practice Address - Fax:612-904-4218
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN042161367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00430495OtherRAILROAD MEDICARE
MN095242700Medicaid
MN233R2LUOtherBLUE CROSS BLUE SHIELD
MN430066278OtherRAILROAD MEDICARE
MN095242700Medicaid
MN233R2LUOtherBLUE CROSS BLUE SHIELD