Healthcare Provider Details

I. General information

NPI: 1487361945
Provider Name (Legal Business Name): DEMIR AHMETOVIC CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2022
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 IRVING AVE
SYRACUSE NY
13210-1602
US

IV. Provider business mailing address

338 JAMESVILLE AVE APT 4A
SYRACUSE NY
13210-3268
US

V. Phone/Fax

Practice location:
  • Phone: 315-470-7111
  • Fax:
Mailing address:
  • Phone: 585-298-3023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number145722
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: