Healthcare Provider Details

I. General information

NPI: 1770520769
Provider Name (Legal Business Name): MICHAEL A WIENCEK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 WESTWOOD DR
HAMILTON MT
59840-2345
US

IV. Provider business mailing address

1200 WESTWOOD DR
HAMILTON MT
59840-2345
US

V. Phone/Fax

Practice location:
  • Phone: 406-363-2211
  • Fax: 406-375-4590
Mailing address:
  • Phone: 406-363-2211
  • Fax: 406-375-4846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN15583
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: