Healthcare Provider Details

I. General information

NPI: 1457857013
Provider Name (Legal Business Name): FOLUSO BAJOWA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 BURDETT AVE
TROY NY
12180-2475
US

IV. Provider business mailing address

PO BOX 840853
DALLAS TX
75284-1323
US

V. Phone/Fax

Practice location:
  • Phone: 518-525-8600
  • Fax:
Mailing address:
  • Phone: 972-233-1999
  • Fax: 972-233-3666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP145428
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number112620
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number749005
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: