Provider Demographics
NPI:1720029325
Name:DUNHAM, DEWAYNE M (CRNA)
Entity Type:Individual
Prefix:
First Name:DEWAYNE
Middle Name:M
Last Name:DUNHAM
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:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56502-0727
Mailing Address - Country:US
Mailing Address - Phone:218-844-2300
Mailing Address - Fax:218-844-2444
Practice Address - Street 1:125 FRAZEE ST E
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3501
Practice Address - Country:US
Practice Address - Phone:218-844-2300
Practice Address - Fax:218-844-2444
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR094125-3367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3957OtherNDBS #
MN2000755OtherMEDICA #
ND56489DUOtherMNBS #
MN12324Medicaid
FM2T933DUOtherMNBS #
MN40087OtherMNBS #
MNHP38638OtherHEALTHPARTNERS #
MNDA9031015530OtherPREFERRED ONE #
ND3579OtherNDBS #
MN142332OtherUCARE #
NDND200082OtherLHS/BANNERHEALTH #
FM2T933DUOtherMNBS #