Healthcare Provider Details

I. General information

NPI: 1013429158
Provider Name (Legal Business Name): ADAM RYAN-LEWIS BOUCHER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2017
Last Update Date: 11/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 HOSPITAL AVE
DANBURY CT
06810-6099
US

IV. Provider business mailing address

23 HUNTINGTOWN RD
NEWTOWN CT
06470-2626
US

V. Phone/Fax

Practice location:
  • Phone: 860-377-4177
  • Fax:
Mailing address:
  • Phone: 860-377-4177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number7352
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: