Provider Demographics
NPI:1821560996
Name:KOLONICH, MATTHEW (CRNA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:KOLONICH
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 1:744 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3505
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7229
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-445-7242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA118986367500000X
WI244546-30367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered