Provider Demographics
NPI:1518955533
Name:ZWAK, JERRY JAY (CRNA)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:JAY
Last Name:ZWAK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:GERALD
Other - Middle Name:JAY
Other - Last Name:ZWAK
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:208 LINDEN DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:SD
Mailing Address - Zip Code:57042-7342
Mailing Address - Country:US
Mailing Address - Phone:605-381-3892
Mailing Address - Fax:507-562-2788
Practice Address - Street 1:208 LINDEN DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:SD
Practice Address - Zip Code:57042-7342
Practice Address - Country:US
Practice Address - Phone:605-381-3892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 140763-1367500000X
SDR026839367500000X
WY21348.0796367500000X
NDR29810367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered