MEDICARE: JERRY JAY ZWAK CRNA

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	R 140763-1	MN
2	367500000X	Certified Registered Nurse Anesthetist	R026839	SD
3	367500000X	Certified Registered Nurse Anesthetist	21348.0796	WY
4	367500000X	Certified Registered Nurse Anesthetist	R29810	ND

General Provider Information

NPI Number	:	1518955533
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY JAY ZWAK CRNA

Provider Business Mailing Address
First Line	:	208 LINDEN DR
Second Line	:
City	:	MADISON
State	:	SD
Zip	:	57042-7342
Country	:	US
Telephone Number	:	605-381-3892
Fax Number	:	507-562-2788

Provider Business Practice Location Address
First Line	:	208 LINDEN DR
Second Line	:
City	:	MADISON
State	:	SD
Zip	:	57042-7342
Country	:	US
Telephone Number	:	605-381-3892
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2005
Last Update Date	:	12/03/2013

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