Provider Demographics
NPI:1710906813
Name:KLOS, CHARLES H (CRNA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:H
Last Name:KLOS
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 1:18601 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:WI
Mailing Address - Zip Code:54773-8605
Mailing Address - Country:US
Mailing Address - Phone:715-538-4361
Mailing Address - Fax:
Practice Address - Street 1:18601 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:WI
Practice Address - Zip Code:54773-8605
Practice Address - Country:US
Practice Address - Phone:715-538-4361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI82758-030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000321162Medicare ID - Type Unspecified