Provider Demographics
NPI:1922567668
Name:BREDESON, TERA L (CRNA)
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:L
Last Name:BREDESON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29266 580TH AVE
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:56243-4503
Mailing Address - Country:US
Mailing Address - Phone:605-490-1829
Mailing Address - Fax:
Practice Address - Street 1:612 S SIBLEY AVE
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55355-3340
Practice Address - Country:US
Practice Address - Phone:320-693-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2332367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered