Provider Demographics
NPI:1386646115
Name:KLOS, KENNETH DONALD JR (CRNA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DONALD
Last Name:KLOS
Suffix:JR
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 1:7595 TIMBERLORE TRL
Mailing Address - Street 2:
Mailing Address - City:COOK
Mailing Address - State:MN
Mailing Address - Zip Code:55723-8728
Mailing Address - Country:US
Mailing Address - Phone:218-290-4381
Mailing Address - Fax:
Practice Address - Street 1:7595 TIMBERLORE TRL
Practice Address - Street 2:
Practice Address - City:COOK
Practice Address - State:MN
Practice Address - Zip Code:55723-8728
Practice Address - Country:US
Practice Address - Phone:218-290-4381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR076202-1367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN891043000Medicaid
MN891043000Medicaid