Healthcare Provider Details

I. General information

NPI: 1912941451
Provider Name (Legal Business Name): MICHAEL W CZAJKA APRN-CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD DIVISION OF PEDIATRIC CARDIOLOGY
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

1465 S GRAND BLVD DIVISION OF PEDIATRIC CARDIOLOGY
SAINT LOUIS MO
63104-1003
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-5674
  • Fax: 314-268-4141
Mailing address:
  • Phone: 314-577-5674
  • Fax: 314-268-4141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number144420
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: