Healthcare Provider Details

I. General information

NPI: 1588613764
Provider Name (Legal Business Name): PETER KWASNIAK RN
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3149 S 77TH ST
MILWAUKEE WI
53219-3753
US

IV. Provider business mailing address

4711 N 100TH ST
WAUWATOSA WI
53225-4734
US

V. Phone/Fax

Practice location:
  • Phone: 414-328-0119
  • Fax:
Mailing address:
  • Phone: 414-461-3134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number115161-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: