Healthcare Provider Details

I. General information

NPI: 1942082904
Provider Name (Legal Business Name): DMITRIY SHKURATSKIY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

IV. Provider business mailing address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-2526
  • Fax: 207-662-6236
Mailing address:
  • Phone: 207-662-2526
  • Fax: 207-662-6236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number51682
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA263067
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: