Provider Demographics
NPI:1184393381
Name:TOLLEFSON, MITCHELL ODEAN (CRNA)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:ODEAN
Last Name:TOLLEFSON
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 1:3701 12TH ST N STE 202
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2253
Mailing Address - Country:US
Mailing Address - Phone:320-258-3090
Mailing Address - Fax:320-258-3090
Practice Address - Street 1:3701 12TH ST N STE 202
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2253
Practice Address - Country:US
Practice Address - Phone:320-258-3090
Practice Address - Fax:320-258-3090
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2458031163W00000X
MN2613367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse