Healthcare Provider Details

I. General information

NPI: 1497088967
Provider Name (Legal Business Name): BRIAN ALEXANDER KAWECKI CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2009
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MEDICAL CENTER DR
FAIRMONT MN
56031-4575
US

IV. Provider business mailing address

1025 MARSH ST
MANKATO MN
56001-4752
US

V. Phone/Fax

Practice location:
  • Phone: 180-023-4614
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberR 147531-7
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1002
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: