Healthcare Provider Details

I. General information

NPI: 1457389868
Provider Name (Legal Business Name): JOHN SAMUEL POLECHETTI CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 S HOUGHTON RD
TUCSON AZ
85748-7632
US

IV. Provider business mailing address

555 PINE ST
LOCKPORT NY
14094-5547
US

V. Phone/Fax

Practice location:
  • Phone: 520-742-9000
  • Fax:
Mailing address:
  • Phone: 716-465-0222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3315571
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: