Provider Demographics
NPI:1417919002
Name:MCCARTHY, GWEN A (CRNA)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:A
Last Name:MCCARTHY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:A
Other - Last Name:VIERKANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:2104 NORTHDALE BLVD NW STE 220
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-3046
Mailing Address - Country:US
Mailing Address - Phone:763-537-6000
Mailing Address - Fax:763-537-6666
Practice Address - Street 1:2104 NORTHDALE BLVD NW STE 220
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55433-3046
Practice Address - Country:US
Practice Address - Phone:763-537-6000
Practice Address - Fax:763-537-6666
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0935528367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN348032100Medicaid
MN430005637Medicare PIN