Healthcare Provider Details

I. General information

NPI: 1629007364
Provider Name (Legal Business Name): SHAHNAZ MOOTABAR CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 PERRYRIDGE RD
GREENWICH CT
06830-4608
US

IV. Provider business mailing address

744 W MICHIGAN AVE
JACKSON MI
49201-1909
US

V. Phone/Fax

Practice location:
  • Phone: 203-661-5330
  • Fax:
Mailing address:
  • Phone: 517-787-6440
  • Fax: 517-787-4146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number020677
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: