Provider Demographics
NPI:1881838753
Name:KACZMARK, TODD WALLACE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:WALLACE
Last Name:KACZMARK
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 1:601 COLLIERS WAY
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-5014
Mailing Address - Country:US
Mailing Address - Phone:304-797-6000
Mailing Address - Fax:
Practice Address - Street 1:601 COLLIERS WAY
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5014
Practice Address - Country:US
Practice Address - Phone:304-797-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV74410163W00000X
PA081278367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse