Provider Demographics
NPI:1316132640
Name:SEVERSON, CARLA M (CRNA)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:M
Last Name:SEVERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:M
Other - Last Name:BETZLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:3701 12TH ST N
Mailing Address - Street 2:STE 202
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2255
Mailing Address - Country:US
Mailing Address - Phone:320-258-3090
Mailing Address - Fax:320-258-3095
Practice Address - Street 1:1406 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1900
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 127052-5367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN447478000Medicaid
MN430006151Medicare PIN