Healthcare Provider Details

I. General information

NPI: 1407736630
Provider Name (Legal Business Name): EVAN BOHDAN KUTNY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 09/08/2025
Certification Date: 09/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 N LAKE DR
MILWAUKEE WI
53211-4508
US

IV. Provider business mailing address

1723 W EDWARD DR
MEQUON WI
53092-2962
US

V. Phone/Fax

Practice location:
  • Phone: 414-585-1000
  • Fax:
Mailing address:
  • Phone: 888-544-4244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number155941
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: