Basic Information
| Provider Information | |||||||||
| NPI: | 1104813047 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRAUSE | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2759 | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549122759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208305900 | ||||||||
| FaxNumber: | 9207385787 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549231243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203615538 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2005 | ||||||||
| LastUpdateDate: | 10/17/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 125032 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 43376200 | 05 | WI | MEDICAID |