Healthcare Provider Details

I. General information

NPI: 1376832139
Provider Name (Legal Business Name): ADAM GARDIZI CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 CHAPEL ST
NEW HAVEN CT
06511
US

IV. Provider business mailing address

1298 HARTFORD TPKE APT 11A
NORTH HAVEN CT
06473-6100
US

V. Phone/Fax

Practice location:
  • Phone: 203-789-3538
  • Fax:
Mailing address:
  • Phone: 916-397-7631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4015
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number004623
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: