Provider Demographics
NPI:1922191758
Name:MALKUCH, ROSS EDWIN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:ROSS
Middle Name:EDWIN
Last Name:MALKUCH
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 1:10050 67TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:PENNOCK
Mailing Address - State:MN
Mailing Address - Zip Code:56279-9788
Mailing Address - Country:US
Mailing Address - Phone:320-599-4207
Mailing Address - Fax:
Practice Address - Street 1:301 BECKER AVE SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3302
Practice Address - Country:US
Practice Address - Phone:320-235-4543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR092898-8367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered