Healthcare Provider Details

I. General information

NPI: 1063014512
Provider Name (Legal Business Name): PETER LIN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

759 CHESTNUT ST
SPRINGFIELD MA
01107-1619
US

IV. Provider business mailing address

153 NEEDLETREE LN
GLASTONBURY CT
06033-3528
US

V. Phone/Fax

Practice location:
  • Phone: 413-795-0754
  • Fax: 413-794-5439
Mailing address:
  • Phone: 302-723-3906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number12.009428
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN10016487
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: