Provider Demographics
NPI:1982605119
Name:HJORT, SAMUEL R (CRNA)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:R
Last Name:HJORT
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 1:5585 HENNA CT
Mailing Address - Street 2:
Mailing Address - City:PINE SPRINGS
Mailing Address - State:MN
Mailing Address - Zip Code:55128-1805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8990 SPRINGBROOK DR NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5884
Practice Address - Country:US
Practice Address - Phone:763-398-0099
Practice Address - Fax:763-398-0124
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1128897367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN07A18HJOtherBCBSMN
MN981345400Medicaid
MN981345400Medicaid