Healthcare Provider Details

I. General information

NPI: 1518955533
Provider Name (Legal Business Name): JERRY JAY ZWAK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: GERALD JAY ZWAK JR. CRNA

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 LINDEN DR
MADISON SD
57042-7342
US

IV. Provider business mailing address

208 LINDEN DR
MADISON SD
57042-7342
US

V. Phone/Fax

Practice location:
  • Phone: 605-381-3892
  • Fax:
Mailing address:
  • Phone: 605-381-3892
  • Fax: 507-562-2788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR 140763-1
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR026839
License Number StateSD
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number21348.0796
License Number StateWY
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR29810
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: