Provider Demographics
NPI:1689763922
Name:HUBER-MANSTROM, CHARLOTTE M (CRNA)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:M
Last Name:HUBER-MANSTROM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CHARLOTTE
Other - Middle Name:M
Other - Last Name:HUBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 5501
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58506-5501
Mailing Address - Country:US
Mailing Address - Phone:701-323-6000
Mailing Address - Fax:701-323-5709
Practice Address - Street 1:300 N 7TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4439
Practice Address - Country:US
Practice Address - Phone:701-323-6000
Practice Address - Fax:701-323-5709
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR18649367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12586Medicaid
ND12586Medicaid
ND4025Medicare PIN