Provider Demographics
NPI:1134188592
Name:KJOS, GREGORY H (CRNA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:H
Last Name:KJOS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:GREG
Other - Middle Name:HAROLD
Other - Last Name:KJOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
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 1:2509 CHERRYWOOD RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-2318
Practice Address - Country:US
Practice Address - Phone:952-546-0595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN039732372500000X
MN100929367500000X
NDR45935367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8052896Medicaid
NC8052896Medicaid