Provider Demographics
NPI:1689633919
Name:MELLESMOEN, GREGORY S (CRNA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
Last Name:MELLESMOEN
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 1:9645 GROVE CIR N STE 250
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4466
Mailing Address - Country:US
Mailing Address - Phone:763-201-8191
Mailing Address - Fax:763-201-8192
Practice Address - Street 1:9645 GROVE CIR N STE 250
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369
Practice Address - Country:US
Practice Address - Phone:763-201-8191
Practice Address - Fax:763-201-8192
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0779700367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN937843000Medicaid
MN937843000Medicaid