Individual
BAI NYONLY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
355 RIDGE AVE, EVANSTON, IL 60202-3328
(847) 316-4000
Mailing address
PO BOX 570, LAKE FOREST, IL 60045-0570
(800) 444-6110
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
209013396
IL
367500000X
Certified Registered Nurse Anesthetist
RN609780
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
367500000X
TAXONOMY
IL
Enumeration date
02/05/2013
Last updated
12/07/2015
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