Healthcare Provider Details

I. General information

NPI: 1649200676
Provider Name (Legal Business Name): STEPHEN G. STUPIK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

184 MILLHAM ST
MARLBOROUGH MA
01752-1024
US

IV. Provider business mailing address

184 MILLHAM ST
MARLBOROUGH MA
01752-1024
US

V. Phone/Fax

Practice location:
  • Phone: 508-485-9416
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN110208
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: