Provider Demographics
NPI:1659328375
Name:EVENSON, BENJAMIN B (CRNA)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:B
Last Name:EVENSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3409
Mailing Address - Country:US
Mailing Address - Phone:218-847-5611
Mailing Address - Fax:218-847-0881
Practice Address - Street 1:1027 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3409
Practice Address - Country:US
Practice Address - Phone:218-847-5611
Practice Address - Fax:218-847-0881
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR161934-8367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FMDA9031025578OtherPREFERRED ONE #
MNHP38328OtherHEALTHPARTNERS #
MN1659328375Medicaid
MN23810OtherLHS/BANNERHEALTH #
MN973137700Medicaid
MN24215OtherNDBS #
MN2001730OtherMEDICA #
FM1113912OtherAMERICA'S PPO/ARAZ #
MN363J3EVOtherMNBS #
MN363J3EVOtherMNBS #
MN973137700Medicaid
MN430006212Medicare PIN