Healthcare Provider Details

I. General information

NPI: 1942342035
Provider Name (Legal Business Name): RICHARD G GOSPODAREK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 N MEADE ST
APPLETON WI
54911-3454
US

IV. Provider business mailing address

2109 E CAPITOL DR STE B
APPLETON WI
54911-8726
US

V. Phone/Fax

Practice location:
  • Phone: 920-731-4101
  • Fax:
Mailing address:
  • Phone: 866-313-0337
  • Fax: 920-739-0124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number132.33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: