Healthcare Provider Details

I. General information

NPI: 1063943819
Provider Name (Legal Business Name): MANISHA P PACHBHAI CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 MCKELVEY RD
BRIDGETON MO
63044-2527
US

IV. Provider business mailing address

424 ORCHARD VIEW CT
GLEN CARBON IL
62034-4337
US

V. Phone/Fax

Practice location:
  • Phone: 314-495-6037
  • Fax: 618-551-3261
Mailing address:
  • Phone: 630-696-7418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2017006741
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: