Basic Information
| Provider Information | |||||||||
| NPI: | 1659328375 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVENSON | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Practice Location | |||||||||
| Address1: | 1027 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT LAKES | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188475611 | ||||||||
| FaxNumber: | 2188470881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 07/16/2012 | ||||||||
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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 | R161934-8 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | DA9031025578 | 01 | FM | PREFERRED ONE # | OTHER | HP38328 | 01 | MN | HEALTHPARTNERS # | OTHER | 1659328375 | 05 | MN | MEDICAID | 23810 | 01 | MN | LHS/BANNERHEALTH # | OTHER | 973137700 | 05 | MN | MEDICAID | 24215 | 01 | MN | NDBS # | OTHER | 2001730 | 01 | MN | MEDICA # | OTHER | 1113912 | 01 | FM | AMERICA'S PPO/ARAZ # | OTHER | 363J3EV | 01 | MN | MNBS # | OTHER |