MEDICARE: JERRY ZWAK ANESTHESIA, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist

General Provider Information

NPI Number	:	1457872996
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JERRY ZWAK ANESTHESIA, PC

Provider Business Mailing Address
First Line	:	400 E 10TH ST
Second Line	:
City	:	WACONIA
State	:	MN
Zip	:	55387-4552
Country	:	US
Telephone Number	:	952-442-9770
Fax Number	:	952-442-3620

Provider Business Practice Location Address
First Line	:	717 S STATE ST STE 100
Second Line	:
City	:	FAIRMONT
State	:	MN
Zip	:	56031-4470
Country	:	US
Telephone Number	:	507-235-3939
Fax Number	:	952-442-3620

Authorized Official
Title or Position	:	OWNER
Name	:	JERRY J ZWAK
Credential	:	CRNA
Telephone Number	:	605-381-3892

Provider Enumeration Date	:	07/06/2017
Last Update Date	:	07/06/2017

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