Provider Demographics
NPI:1457630436
Name:VAN OVERBEKE, TESSA MARIE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:TESSA
Middle Name:MARIE
Last Name:VAN OVERBEKE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TESSA
Other - Middle Name:MARIE
Other - Last Name:WIRTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:640 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2502
Mailing Address - Country:US
Mailing Address - Phone:651-254-3456
Mailing Address - Fax:
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 163130-0367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered