Healthcare Provider Details

I. General information

NPI: 1174515506
Provider Name (Legal Business Name): JOHN WESLEY ZIEBARTH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BUNKER HILL DR
AITKIN MN
56431-1865
US

IV. Provider business mailing address

29561 395TH PL
AITKIN MN
56431-4444
US

V. Phone/Fax

Practice location:
  • Phone: 218-927-5522
  • Fax:
Mailing address:
  • Phone: 218-927-9941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR-119021-0
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: