Basic Information
| Provider Information | |||||||||
| NPI: | 1891986923 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENGELSTAD | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 523 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BRAINERD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564013054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188292861 | ||||||||
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| Practice Location | |||||||||
| Address1: | 523 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BRAINERD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564013054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188292861 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2007 | ||||||||
| LastUpdateDate: | 01/07/2016 | ||||||||
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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 | 55611 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | 1497003081 | KS | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | P00625414 | 01 | KS | RR MEDICARE GROUP CQ2302 | OTHER | 145989 | 01 | KS | BCBS OF KS | OTHER | 200508500A | 05 | KS | MEDICAID |