MEDICARE: MR. LAWRENCE WAYNE WIECZOREK 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	1-064713	AL

General Provider Information

NPI Number	:	1881650257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LAWRENCE WAYNE WIECZOREK CRNA

Provider Business Mailing Address
First Line	:	32 POST OAK LN
Second Line	:
City	:	JACKSONS GAP
State	:	AL
Zip	:	36861-2545
Country	:	US
Telephone Number	:	251-769-1900
Fax Number	:

Provider Business Practice Location Address
First Line	:	32 POST OAK LN
Second Line	:
City	:	JACKSONS GAP
State	:	AL
Zip	:	36861-2545
Country	:	US
Telephone Number	:	251-769-1900
Fax Number	:

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

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	07/08/2007

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