Provider Demographics
NPI:1861441255
Name:MENCKE, PAUL BRIAN (CRNA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:BRIAN
Last Name:MENCKE
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 1:8838 LAKE JANE TRL N
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-8518
Mailing Address - Country:US
Mailing Address - Phone:651-770-5258
Mailing Address - Fax:
Practice Address - Street 1:559 CAPITOL BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-2101
Practice Address - Country:US
Practice Address - Phone:651-232-2000
Practice Address - Fax:651-232-2118
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR080775-3367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN138742100Medicaid