Healthcare Provider Details

I. General information

NPI: 1447637483
Provider Name (Legal Business Name): ANDREY POPOV CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

267 GRANT ST
BRIDGEPORT CT
06610-2870
US

IV. Provider business mailing address

593 MAIN ST UNIT 202
RIDGEFIELD CT
06877-3836
US

V. Phone/Fax

Practice location:
  • Phone: 203-384-3000
  • Fax:
Mailing address:
  • Phone: 302-864-7408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number128140
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9689
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: