Healthcare Provider Details

I. General information

NPI: 1710906813
Provider Name (Legal Business Name): CHARLES H. KLOS C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18601 LINCOLN ST
WHITEHALL WI
54773-8605
US

IV. Provider business mailing address

18601 LINCOLN ST
WHITEHALL WI
54773-8605
US

V. Phone/Fax

Practice location:
  • Phone: 715-538-4361
  • Fax:
Mailing address:
  • Phone: 715-538-4361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number82758-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: