Basic Information
| Provider Information | |||||||||
| NPI: | 1336188218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CALLAHAN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6001 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581086001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 32ND AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581036132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013648000 | ||||||||
| FaxNumber: | 7013648078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 05/11/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R17494 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 50228CA | 01 | ND | MNBS # | OTHER | 967144 | 01 | ND | ARAZ # | OTHER | DA9011015518 | 01 | ND | PREF 1 # | OTHER | 26286 | 01 | ND | NDBS # | OTHER | 142325 | 01 | ND | UCARE # | OTHER | HP38622 | 01 | ND | HEALTHPARTNERS # | OTHER | 2000744 | 01 | ND | MEDICA INNOVIS # | OTHER | 12659 | 05 | ND | MEDICAID | 817743100 | 05 | ND | MEDICAID | 2000743 | 01 | ND | MEDICA FGO # | OTHER |