Healthcare Provider Details

I. General information

NPI: 1558844738
Provider Name (Legal Business Name): GRIGORIY GRIGORYAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2018
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 BEAMAN ST
CLINTON NC
28328-2603
US

IV. Provider business mailing address

PO BOX 890235
CHARLOTTE NC
28289-0235
US

V. Phone/Fax

Practice location:
  • Phone: 240-566-1603
  • Fax: 770-701-6718
Mailing address:
  • Phone: 844-246-1591
  • Fax: 770-701-6718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number5966
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number260470
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: