Provider Demographics
NPI:1992174940
Name:MARONG, KEMO (CRNA)
Entity type:Individual
Prefix:MR
First Name:KEMO
Middle Name:
Last Name:MARONG
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 1:9618 SCOTT LN N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-5101
Mailing Address - Country:US
Mailing Address - Phone:320-291-8635
Mailing Address - Fax:
Practice Address - Street 1:9618 SCOTT LN N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-5101
Practice Address - Country:US
Practice Address - Phone:320-291-8635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCRNA 1801367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered