Healthcare Provider Details

I. General information

NPI: 1386981777
Provider Name (Legal Business Name): MATTHEW JAMES JANEZIC CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E 3RD ST DULUTH CLINIC
DULUTH MN
55805-1951
US

IV. Provider business mailing address

1615 MAPLE LN
ASHLAND WI
54806-3626
US

V. Phone/Fax

Practice location:
  • Phone: 218-783-8364
  • Fax:
Mailing address:
  • Phone: 715-685-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number8200
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8200
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: