Provider Demographics
NPI:1306588256
Name:DZIEWIT, RICHARD ANTON (CRNA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ANTON
Last Name:DZIEWIT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 N MORRISON ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-2908
Mailing Address - Country:US
Mailing Address - Phone:612-730-1208
Mailing Address - Fax:
Practice Address - Street 1:200 THEDA CLARK MEDICAL PLZ
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2721
Practice Address - Country:US
Practice Address - Phone:920-729-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI137484367500000X
390200000X
WI199571367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty