Provider Demographics
NPI:1710006887
Name:ENGELBREKTSON, MARC LESLIE (CRNA)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:LESLIE
Last Name:ENGELBREKTSON
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 1:2585 23RD AVE S.
Mailing Address - Street 2:STE. A. PRAIRIE ORAL SURGERY
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103
Mailing Address - Country:US
Mailing Address - Phone:701-478-4404
Mailing Address - Fax:701-478-4407
Practice Address - Street 1:2585 23RD AVE S
Practice Address - Street 2:STE A.
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-478-4404
Practice Address - Fax:701-478-4407
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND036098367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12355Medicaid
MN488843000Medicaid
ND24266OtherBLUE CROSS BLUE SHIELD