Provider Demographics
NPI:1417315185
Name:CENTRAL MINNESOTA ANESTHESIA PROVIDERS, PLLC
Entity Type:Organization
Organization Name:CENTRAL MINNESOTA ANESTHESIA PROVIDERS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JANDIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:320-492-6506
Mailing Address - Street 1:PO BOX 7185
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-7185
Mailing Address - Country:US
Mailing Address - Phone:320-492-6506
Mailing Address - Fax:
Practice Address - Street 1:22415 STATE HIGHWAY 15
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTA
Practice Address - State:MN
Practice Address - Zip Code:56301-9207
Practice Address - Country:US
Practice Address - Phone:320-492-6506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-09
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN38209207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN38209OtherMINNESOTA LICENSE