Healthcare Provider Details

I. General information

NPI: 1255387775
Provider Name (Legal Business Name): JACOB D KOTZIAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 12/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 PARK AVE
MINNEAPOLIS MN
55415-1623
US

IV. Provider business mailing address

701 PARK AVE
MINNEAPOLIS MN
55415-1623
US

V. Phone/Fax

Practice location:
  • Phone: 612-873-3152
  • Fax: 612-904-4218
Mailing address:
  • Phone: 612-873-6005
  • Fax: 612-630-8242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number074418
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: