Provider Demographics
NPI:1437623535
Name:CRAWFORD, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:CRAWFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 IRONWOOD AVE NW
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-1020
Mailing Address - Country:US
Mailing Address - Phone:218-371-8898
Mailing Address - Fax:
Practice Address - Street 1:13911 RIDGEDALE DR STE 404B
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1777
Practice Address - Country:US
Practice Address - Phone:952-932-9012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR39886367500000X
MN2383699367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered