Basic Information
Provider Information | |||||||||
NPI: | 1164480299 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRICKSON | ||||||||
FirstName: | DENISE | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1680 DIAGONAL RD | ||||||||
Address2: |   | ||||||||
City: | WORTHINGTON | ||||||||
State: | MN | ||||||||
PostalCode: | 561871008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5073723800 | ||||||||
FaxNumber: | 5073723806 | ||||||||
Practice Location | |||||||||
Address1: | 1680 DIAGONAL RD | ||||||||
Address2: |   | ||||||||
City: | WORTHINGTON | ||||||||
State: | MN | ||||||||
PostalCode: | 561871008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5073723800 | ||||||||
FaxNumber: | 5073723806 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | D-083572 | IA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 28510 | 01 | IA | BLUE CROSS BLUE SHIELD | OTHER | 0226423 | 05 | IA |   | MEDICAID | P00057073 | 01 | IA | RAILROAD MEDICARE | OTHER |