Provider Demographics
NPI:1871511410
Name:ELLINGSON, LEE ALLEN (CRNA)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:ALLEN
Last Name:ELLINGSON
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 1:10170 180TH ST
Mailing Address - Street 2:
Mailing Address - City:WADENA
Mailing Address - State:MN
Mailing Address - Zip Code:56482-4094
Mailing Address - Country:US
Mailing Address - Phone:218-631-9054
Mailing Address - Fax:
Practice Address - Street 1:415 JEFFERSON ST N
Practice Address - Street 2:
Practice Address - City:WADENA
Practice Address - State:MN
Practice Address - Zip Code:56482-1264
Practice Address - Country:US
Practice Address - Phone:218-631-7589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR23296367500000X
MNR1388019367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN99999Medicare UPIN