Healthcare Provider Details

I. General information

NPI: 1750318440
Provider Name (Legal Business Name): ANDREW JOHN POULOS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

667 EASTLAND AVE SE
WARREN OH
44484-4503
US

IV. Provider business mailing address

4135 BOARDMAN CANFIELD RD SUITE 101
CANFIELD OH
44406-9803
US

V. Phone/Fax

Practice location:
  • Phone: 330-286-5330
  • Fax: 330-286-5396
Mailing address:
  • Phone: 330-286-5330
  • Fax: 330-286-5396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN273223
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: