Provider Demographics
NPI:1720287154
Name:PETTY, KENDALL (CRNA)
Entity type:Individual
Prefix:
First Name:KENDALL
Middle Name:
Last Name:PETTY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8990 SPRINGBROOK DR NW
Mailing Address - Street 2:SUITE 250
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5850
Mailing Address - Country:US
Mailing Address - Phone:763-398-0099
Mailing Address - Fax:763-398-0124
Practice Address - Street 1:8990 SPRINGBROOK DR NW
Practice Address - Street 2:SUITE 250
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5850
Practice Address - Country:US
Practice Address - Phone:763-398-0099
Practice Address - Fax:763-398-0124
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 135220-7367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN430917000Medicaid
MN53L81PEOtherBCBSMN
MN430006044Medicare PIN