Healthcare Provider Details

I. General information

NPI: 1336595065
Provider Name (Legal Business Name): SANJEEV WADHWA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2016
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 HERRICK ST
BEVERLY MA
01915-1790
US

IV. Provider business mailing address

91 HAVERHILL ST
NORTH READING MA
01864-2816
US

V. Phone/Fax

Practice location:
  • Phone: 978-816-2018
  • Fax:
Mailing address:
  • Phone: 617-304-5544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN2262485
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: