Healthcare Provider Details

I. General information

NPI: 1134188592
Provider Name (Legal Business Name): GREGORY H KJOS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: GREG HAROLD KJOS CRNA

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2509 CHERRYWOOD RD
MINNETONKA MN
55305-2318
US

IV. Provider business mailing address

744 S WEBSTER AVE
GREEN BAY WI
54301-3505
US

V. Phone/Fax

Practice location:
  • Phone: 952-546-0595
  • Fax:
Mailing address:
  • Phone: 920-445-7226
  • Fax: 920-445-7229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number039732
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number100929
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR45935
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: