Healthcare Provider Details

I. General information

NPI: 1215983929
Provider Name (Legal Business Name): RICHARD S NIEDZIELSKI CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 CATLIN ST
BUFFALO MN
55313-1947
US

IV. Provider business mailing address

14700 28TH AVE N SUITE 20
PLYMOUTH MN
55447-4835
US

V. Phone/Fax

Practice location:
  • Phone: 763-682-1212
  • Fax:
Mailing address:
  • Phone: 763-559-3779
  • Fax: 763-450-3986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR091437-4
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: