Basic Information
| Provider Information | |||||||||
| NPI: | 1073516266 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLICK | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553874552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524429770 | ||||||||
| FaxNumber: | 9524423620 | ||||||||
| Practice Location | |||||||||
| Address1: | 717 S STATE ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | FAIRMONT | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560314470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072353939 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 04/28/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R0799010 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 27G81KL | 01 | MN | BLUE CROSS MN | OTHER | 430056096 | 01 | MN | PALMETTO GBA RR MC | OTHER | 177742400 | 05 | MN | MEDICAID | 2552 | 01 | MN | ARAZ | OTHER | 143425200 | 01 | MN | US DEPARTMENT OF LABOR | OTHER | 1103036 | 01 | MN | ARAZ | OTHER |